All inspections: Weston General Hospital

Community & mental health inspection reports for Weston General Hospital can be found at Weston Area Health NHS Trust.

We conducted this focused inspection to follow up on concerns identified in a Section 29A Warning Notice served in April 2019, following a comprehensive inspection of the service in February 2019. The warning notice set out the following areas of concern, where significant improvement was required by 5 July 2019:

Urgent & Emergency Care

There were not effective systems to monitor safety and risk. Incidents were not always investigated promptly and there was inadequate evidence to demonstrate that identified risks, incidents, deaths and unexpected outcomes were regularly discussed, and learning shared to improve patient safety.
There was inadequate oversight of clinical audit and insufficient evidence that audit was used to drive improvements in safety and patient outcomes.
Staff in the emergency department did not receive adequate support, training and supervision to carry out their roles and responsibilities. Junior doctors expressed concerns about a lack of supervision and engagement from some senior medical staff. There was inadequate oversight of nurse training.

Specialist Community Mental Health services for children and young people

Staff in the child and adolescent mental health service (CAMHS) were not actively monitoring the risks of young people waiting for assessment and treatment
Staff in CAMHS were not documenting risk assessments for all young people receiving care within the service
Staff in CAMHS did not maintain young people’s confidentiality through safe record keeping.
Managers did not effectively assess or monitor quality, safety and risk in CAMHS.

At this follow up inspection we found the trust had achieved some progress in addressing our concerns; however, there was still work to do. We judged that the requirements of the warning notice had not been fully met in Urgent and Emergency Care. We judged that the specific requirements of the warning notice had been met within the Specialist Community Mental Health services for children and young people, although there remained actions for the service to take.

In Urgent and Emergency Care we found:

Governance systems were still not operating effectively.
There was limited assurance with regard to the skills of nursing staff in the emergency department. There was no structured training plan or system of staff supervision.
Whilst junior doctors were mostly positive about the support and supervision they received, there remained some concerns, particularly about support at weekends.

However:

Many changes had taken place since our last inspection, including senior staff changes. There had been concerted efforts to make improvements and a positive “can do” attitude was evident among senior staff.
Governance systems and processes had been reviewed and strengthened and a new governance lead for the emergency department had been appointed.
Quality improvement meetings had been established, including mortality and morbidity reviews, where deaths and unexpected outcomes were reviewed.
National audits were being used to drive improvement and clinical guidelines were being reviewed to ensure they were up to date and fit for purpose.
A competency framework for all grades of nursing staff working in ED had been developed and a practice development nurse had been appointed to support the oversight and delivery of training.

In Specialist Community Mental Health services for children and young people we found:

During this inspection we found:

The risk of young 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 service had secured funding for an electronic care recording system and were in the process of exploring which application to purchase.
The trust had recruited a clinical nurse lead to maintain oversight of clinical activity within the team, this included management of caseloads, waiting lists, supervision and training.
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.
Managers had developed processes and policies to ensure the service was managing risk appropriately and governance structures had been put in place although were not yet embedded fully. 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.
Managers were aware of incidents that had occurred and were able to give us examples of how practice had changed to prevent incidents reoccurring. We saw evidence that managers were more engaged in learning from incidents than they were at the previous inspection.
Managers were monitoring staff stress levels and encouraging staff to provide feedback.

However:

The use of paper care records continued to cause risk. Reported incidents showed occurrences of a record being misplaced, a referral being missed and a duplicate patient record.
Whilst risks to patients from ligature points had been identified, no clear actions had been taken to mitigate these risks, and we did not see a clear plan that would address this. This meant that vulnerable children remained at risk.

Nigel Acheson

Deputy Chief Inspector of Hospitals (London and South), on behalf of the Chief Inspector of Hospitals

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.

We undertook this focused inspection to follow up on the concerns identified in a Section 29A Warning Notice served in March 2017, following an inspection of the trust. The warning notice set out the following areas of concern, where significant improvement was required:

Systems or processes to manage patient flow through the hospital did not operate effectively to ensure care and treatment was being provided in a safe way for patients and to reduce crowding in the emergency department.
There was inadequate hospital-wide support for the emergency department when in escalation. The escalation process was not responsive, and the bed management function was not operating effectively.
The emergency department was the single point of entry to the hospital for both emergency and expected patients, contributing to crowding. There were no direct admission pathways. This meant all GP referrals were seen in the emergency department. The emergency department did not make optimum use of the ambulatory care unit to help to improve flow and reduce crowding.
Patients spent too long in the emergency department. There were delays in specialist review of patients, particularly at night, and admission delays from decision to admit.
Crowding in the emergency department was a frequent occurrence. Patients queued in the corridor when there were no cubicles available. This was not an appropriate or safe place for care and treatment. Patients had no access to supplied oxygen and suction, call bells or facilities to store their belongings keep their records secure.

We conducted our first follow-up inspection in December 2017. Although the trust had achieved progress in addressing our concerns, we judged that the requirements of the warning notice had not been fully met.

We conducted this second follow-up inspection on 13 August 2018. The inspection was unannounced. The inspection focused solely on the issues identified in the warning notice, as described above.

The trust had achieved good progress in addressing our concerns. We judged that the requirements of the warning notice had been met.

We found:

A number of improvements had taken place since the comprehensive inspection published in March 2017. These included new systems, staff changes and reconfiguration of premises. Changes appeared to have yielded benefits, seen, for example, in improved emergency department performance. However, this improvement must be viewed in the context of an emergency department which was currently closed at night and systems had yet to be tested when the department was open 24 hours a day.

There was a protocol for the management of accident and emergency patients waiting in the adjacent corridor which was understood by staff.

For patients being treated in the corridor, records could be safely stored in lockable cupboards.

Systems and processes to manage patient flow through the hospital had been reviewed and strengthened. Senior staff were driving change and improvement.

There was evidence of regular dialogue between the patient flow team and the emergency department. There was a clear escalation process and action cards for individuals, teams and departments if demand outstripped capacity.

A primary care practitioner streaming unit were established to support the emergency department, allowing low acuity patients to be diverted from the emergency department.

The trust had improved its performance against the standard which requires that 95% of patients are discharged, admitted or transferred within four hours.

There had been a continual improvement from February 2018 in delayed specialist review of patients.

Use of the corridor in the emergency department to accommodate patients at times of crowding had reduced, and curtains were available for use in the corridor to preserve the dignity of patients.

The trust had employed ‘progress trackers’: administrative staff who were responsible for escalating any patients in the department who were at risk of breaching targets.

However:

Nurse staffing at the time of our inspection was below establishment and recruitment and retention remained a challenge for the department.

The capacity of the ambulatory emergency care unit was affected by vacancies within the unit.

A recent upgrade to the IT systems within the department made it difficult for staff in the ambulatory emergency care and primary care practitioner streaming unit to take appropriate patients from the emergency department’s waiting area.

Staff in the emergency department and the ambulatory emergency care unit did not work together to resolve common issues.

The communication device for discussing GP referrals was held by a non-clinical member of the patient flow team. Staff in the emergency department told us that this was inefficient as the non-clinical staff were not able to make clinical decisions about the most appropriate pathway for a patient.

The trust should:

Ensure executive staff are aware when the corridor is in use, as per the trust’s policy.
Improve systems to allow ambulatory emergency care staff to effectively take appropriate patients from the waiting area.
Improve communication between the emergency department and ambulatory emergency care unit.
Ensure the communication device for discussing GP referrals is held by a clinical member of staff to make appropriate decisions regarding pathways for patients.

Edward Baker

Chief Inspector of Hospitals

We undertook this focused inspection to follow up on the concerns identified in a Section 29A Warning Notice served in March 2017, following an inspection of the trust. The warning notice set out the following areas of concern, where significant improvement was required:

Systems or processes to manage patient flow through the hospital did not operate effectively to ensure care and treatment was being provided in a safe way for patients and to reduce crowding in the emergency department.
There was inadequate hospital-wide support for the emergency department when in escalation. The escalation process was not responsive and the bed management function was not operating effectively.
The emergency department was the single point of entry to the hospital for both emergency and expected patients, contributing to crowding. There were no direct admission pathways. This meant all GP referrals were seen in the emergency department. The emergency department did not make optimum use of the ambulatory care unit to help to improve flow and reduce crowding.
Patients spent too long in the emergency department. There were delays in specialist review of patients, particularly at night, and admission delays from decision to admit.
Crowding in the emergency department was a frequent occurrence. Patients queued in the corridor when there were no cubicles available. This was not an appropriate or safe place for care and treatment. Patients had no access to supplied oxygen and suction, call bells or facilities to store their belongings keep their records secure.

We conducted this follow-up inspection on 12 December 2017. The inspection was unannounced. The inspection focused solely on the issues identified in the warning notice, as described above.

The trust had achieved significant progress in addressing our concerns; however, there was still work to do. We judged that the requirements of the warning notice had not been fully met.

We found:

Many positive changes had taken place since our last visit; new systems, staff changes and reconfiguration of premises. Further changes were in the pipeline. Some changes were very recent, not fully embedded and, in some cases not fully understood by staff. Changes appeared to have yielded benefits, seen, for example, in improved emergency department performance. However, this improvement must be viewed in the context of an emergency department which was closed at night and systems had yet to be tested when the department was fully operational.
There was a lack of clarity and understanding amongst clinicians with regard to admission pathways. New processes had not been formalised or tested.
The capacity and effectiveness of the ambulatory emergency care (AEC) unit was limited due to space and staffing. At the time of our inspection it operated during the day, Monday to Friday only. We were not able to obtain any data with regard to the effectiveness of the AEC and its impact in reducing crowding in the emergency department.
On the day of our inspection patients experienced lengthy delays for admission. On arrival in the emergency department at 8am we found there were 17 patients who had attended the department the day before and were awaiting admission. We requested data and analysis in respect of these delays and historical data to show how long patients waited in the emergency department for admission, following the decision to admit. The trust did not currently capture this data.
We were unable to obtain data in respect of the time patients waited for specialist review; we were told this had improved but surgical reviews were delayed at night.
The corridor in the emergency department continued to be used to accommodate patients when all cubicles were full. Although senior staff told us this area was used in exceptional circumstances only, data provided by the trust showed that use was increasing. In October and November 2017, 59 and 73 patients respectively spent time in the corridor.
On the day of our inspection the corridor was in use. The physical constraints we described at our last inspection remained. Temporary curtains were in place and were used to preserve patients’ privacy and dignity when being examined. However, use of curtains created a confined space in which staff examined and treated patients. Patients’ records were not stored securely.
We were concerned that unsuitable patients were placed in the corridor on arrival in the emergency department. This included a patient who was living with dementia, who was confused and combatant and a patient who, on the advice of paramedics, required cardiac monitoring. Following our inspection the trust investigated our concerns in relation to the placement of these patients in the corridor. They assured us that the nurse in charge had full oversight of the acuity of all of the patients in the department and there were no other suitable patients who could be moved to free up a cubicle space.
The nurse in charge on the day of our inspection was not appropriately supported to manage patient flow in the emergency department.

However,

There had been a thorough review of systems and processes to improve capacity management and patient flow, to reduce crowding in the emergency department.
The patient flow team had been reconfigured and the bed management process had been re-designed. Staff were embracing new ways of working and were clear about their individual and team responsibilities.
Bed meetings were structured and focused on creating capacity. Meetings were well led and well attended. There was senior presence and staff told us this was the norm.
The trust had taken a number of steps to reduce length of inpatient stay. This included education campaigns and promotion of management tools to increase focus on patient flow.
The trust had established an integrated discharge team and an acute frailty assessment service to support complex discharges.
The discharge lounge had been reconfigured to become more effective and there were plans to increase its capacity and utilization.
There had been a lot of work undertaken to develop alternative admission pathways to reduce congestion in the emergency department.
Primary care streaming had very recently been introduced. Appropriate patients (with minor illness) were directed on arrival in the emergency department, to see an advanced nurse practitioner in the adjacent ambulatory care unit.
The ambulatory emergency care Unit was re-modelling pathways and developing direct access pathways for GPs and the ambulance service. There were plans to increase its capacity to assess a greater proportion of expected and emergency patients.
The trust’s performance against the national standard which requires that patients are admitted, transferred or discharged within four hours had improved.
Senior clinicians told us that specialist review of patients in the emergency department was subject to fewer delays. There was a registrar physician based in the emergency department to facilitate early review of patients. There was positive feedback about the introduction of a common clerking documentation, which reduced duplication and saved time. Clerking is the recording of a patient’s history, including initial investigations.
We were pleased to note that use of the corridor for patients in ED had significantly reduced although this was now beginning to increase again. Staff told us this area was only used in exceptional circumstances. Staff were required to seek permission from senior managers to use the corridor and permission was only granted if safe levels of staffing were in place.
We observed the corridor being used to accommodate patients on the day of our visit. The area was staffed at all times, to mitigate the environmental risks associated with this area.

The trust must:

Continue to drive change to improve patient flow and reduce crowding in the emergency department.
Formalise new systems and processes and ensure the engagement of staff in the change process so that new ways of working are understood.
Embed and test effectiveness of new systems and processes through audit.
Capture information and monitor delays in respect the time patients wait for admission following the decision to admit and any delays in specialist review of patients in the emergency department.
Ensure that patients’ records are secured to ensure confidentiality is maintained.

In addition the trust should:

Ensure the nurse in charge in the emergency department is appropriately supported to enable efficient coordination of patient flow in the department.

Edward Baker

Chief Inspector of Hospitals

We rated Weston General Hospital as requires improvement overall with the urgent and emergency care services rated as inadequate, medicine and older people as requires improvement and surgery and critical care as good.

There had been some progress since our previous inspection with surgery and critical care moving from requires improvement to good overall. Medical care also demonstrated improvement with safety and well led now rated requires improvement from inadequate. However, the ongoing pressures on the emergency department continued to be reflected in the ratings with safety remaining as inadequate and responsive and well led failing to improve also being rated inadequate. Patient flow had not been sufficiently improved since our last inspection and responsive in medical care was rated as inadequate.

As part of this inspection, CQC piloted an enhanced methodology relating to the assessment of mental health care delivered in acute hospitals; the evidence gathered using the additional questions, tested as part of this pilot, has not contributed to our aggregation of judgements for any rating within this inspection process. Whilst the evidence is not contributing to the ratings, we have reported on our findings in the report.

We had serious concerns that systems or processes to manage patient flow through the hospital were not operating effectively and did not ensure care and treatment was being provided in a safe way for service users. We served the trust with a Section 29A warning notice on 24 March 2017. The notice required the trust to make the significant improvements by 15 May 2017 in the following areas:

Systems or processes to manage patient flow through the hospital must operate effectively to ensure care and treatment is being provided in a safe way for patients and to reduce crowding in the emergency department.

Review the emergency department as the single point of entry to the hospital for both emergency and expected patients to reduce crowding.

Ensure access to a specialist senior doctor to review patients overnight in the emergency department is timely and does not delay patient admission to wards.
Ensure the use of the corridor in the emergency department is an appropriate and safe area for patients to receive care and treatment.

Our key findings were as follows:

We found the trust had been under increasing pressure to manage flow in the hospital for several months and the emergency department was under sustained pressure from an increase in attendances.
There was a lack of support for the emergency department from the wider hospital services and a lack of trust wide ownership around patient flow. This meant patients were frequently and consistently not able to access services in a timely way and some patients experienced unacceptable waits for some services.
There was a fragile medical infrastructure in the emergency department with a crucial reliance on locum medical staff at consultant and middle grade positions. However, shortly after our on-site inspection a recent partnership with another local acute trust had secured some input for clinical leadership one day a week.
The corridor area in the emergency department was frequently used when there were more patients than cubicles available. This was not a suitable or safe environment for patients to receive emergency care and treatment and was not fit for purpose.
The trust mortality rate had been higher than the expected level for the recent reporting periods of July 2015 to June 2016. A review of mortality and an associated action plan were in place; however the lack of recorded minutes and actions in speciality mortality review meetings was of concern. It was unclear if learning was shared or action taken as a result of reviews of patient deaths.
Since our previous inspection there had been some changes to the executive team with some people now in permanent roles and others being interim positions. More changes were due in April 2017 with a new medical director and director of operations starting in post. While the current executives worked well together they had been drawn into managing operational pressures in the emergency department on a regular basis. The new executives could lead to further change and approach to a team already under pressure and ‘wearing many hats’ due to the small trust and less senior roles.
A review of governance had begun to implement change but was immature and lacking in clinical leadership at directorate level to provide robust assurance.

Safe

We rated safety as requires improvement overall with safety in urgent and emergency care rated as inadequate, in medicine it was requires improvement and good in surgery and critical care.
Medical staffing levels and skill mix did not ensure safe care at all times in the emergency department and medical wards. There was a fragile medical infrastructure with a critical reliance on locum medical staff at consultant and middle grade positions.
In the emergency department there was no clinical lead consultant medical leadership to focus direction and ensure safety was a high priority.
There were risks to children that medical staff did not have the appropriate skills and capability due to the lower numbers seen of emergency cases of paediatric cardiac arrest or deteriorating child.
The facilities in the emergency department did not all meet patients’ needs and were inappropriate. The corridor area was not a suitable or safe environment for patients to receive emergency care and treatment and was not fit for purpose. This area posed environmental risks and was a poor patient experience.
There had been little progress in reducing mortality at the trust. While an action plan was in place, progress with some areas was limited and there was a lack of attendance and accountability at the mortality meetings and learning points and actions were not evident in all specialities.
Trust policy for the management of medicines was not always adhered to, for example checking of controlled drugs, recording of medicine refrigerator temperatures and recording of signatures of agency nurses and locum doctors.
Pharmacy staffing levels did not meet service, clinical and medicines governance demands and achieve medicines related Commissioning for Quality and innovation (CQUINS) and Carter model hospital indicators and therefore protect patient safety.
Mandatory training compliance required improvement, particularly in basic life support and dementia awareness. With doctors not reaching compliance targets more often than nursing staff.
We found a fire exit in the stroke unit was blocked and could cause delay of evacuation in the event of a fire. The trust took action when we raised the issue but it continued to be poorly managed and had not been fully rectified on our unannounced visit. This was included on the risk register but not being managed effectively.

However:

There had been no cases of methicillin-susceptible Staphylococcus aureus (MRSA) in the previous year.
There were systems and processes in place to reduce the risk of cross infection and clinical areas and wards we visited were visibly clean.
Sepsis screening and pathways were in place with early treatment seen to be improving. Within nine months, the number of patients with identified sepsis receiving antibiotics within one hour had increased from 11% to 78%.
Staff took a proactive approach to safeguarding and were aware of local safeguarding procedures for both adults and children. Although there were some delays in investigations due to staffing pressures.
A substantial amount of work had been carried out on National Safety Standards for Invasive Procedures (NatSSIPs). The changes were being embedded in to practice across all surgical departments.
A prevention and reduction for pressure ulcers action plan had been created in November 2016, the action plan was in its infancy, however, processes were being put in place to improve awareness and ensure safe management of pressure ulcers.
Staff understood their responsibility to report concerns and incidents. The duty of candour was mostly understood by staff and staff openness and transparency about safety was encouraged.

Effective

We rated effective as requires improvement overall with urgent and emergency care and medicine and older people rated as requires improvement and surgery and critical care as good.
The hospital did not have an orthopaedic-geriatric service in line with national guidance due to recruitment problems.
Not all patients with fractured neck of femurs were operated on within 48 hours of admission, or admitted to an orthopaedic ward within four hours in line with national guidelines.
When benchmarked against other hospitals the trust performed worse than the England average in a number of national audit programmes including: the 2015 Bowel Cancer Audit where the hospital had a mixed performance compared to other hospitals. The trust scored ‘E’ for patients being directly admitted to the stroke unit. The heart failure audit for 2015 showed the trust was worse than the England and Wales average for three of the four standards relating to in-hospital care and four of the seven standards relating to discharge. The 2015 National Diabetes Inpatient Audit (NaDIA) scored better than the England average in five metrics and worse than the England average in 12 metrics. Quality improvements were not always sustained and audit findings were not shared and used effectively to improve quality and patient outcomes.
The inability to recruit senior medical staff led to a lack of clinical leadership and did not provide sufficient support to junior doctors and ensure optimum patient safety at times of increased capacity.
Multidisciplinary working was not all coordinated to provide effective care for patients. In the emergency department there were professional working relationship breakdowns between doctors and established routines which had not been effectively addressed. These impacted on patients as early speciality review was delayed and patients had to wait in the emergency department.
A dietician audit identified poor performance for the completion of the malnutrition universal screening tool (MUST) assessments within 24 hours of admission, where the MUST was not always completed accurately.

However:

Care and treatment was planned in line with current evidence based guidance. Clinical care pathways and toolkits were developed in accordance with national guidelines.
Patients received effective care in the critical care unit with practices and protocols in line with guidance and patients had the outcomes that should be expected.
There was an effective stroke pathway in place through the emergency department.
Patients’ consent to care and treatment was sought in line with legislation and guidance. Most staff had a clear understanding of the Mental Capacity Act 2005, Deprivation of Liberty Safeguards and patient consent.
Patients had their pain assessed regularly and managed promptly to ensure they remained as comfortable as possible.
Since the last inspection, the hospital had employed a dedicated acute pain nurse in line with the Royal College of Anaesthetists Accreditation Standards.
There was strong multidisciplinary working across wards and departments.
The Patient Reporting Outcomes Measures (PROMS) and the National Joint Registry for the period of April 2015 to March 2016 showed that more patients who had groin hernia operations felt better and fewer patients felt worse after their treatment than the England average.
The hospital performed well in the 2016 National Emergency Laparotomy Audit (NELA). The hospital achieved a green (>80%) rating for high-risk cases with a consultant surgeon and anaesthetist present in the theatre and of highest-risk cases admitted to critical care post-operatively.

Caring

Caring was rated as good overall and good for each core service.
Staff in the emergency department remained professional and capable while under considerable pressure in a full to capacity and pressured environment. They were seen to take the time to speak with patients and those close to them in a respectful and considerate way. We saw staff delivering compassionate care and treating patients with kindness, dignity and respect. Privacy and confidentiality was respected as much as was possible considering the constraints of the environment.
Patients who were delayed in the emergency department received nursing care and support, and were transferred to beds for their comfort and food and drink provided.
Patients on surgical wards commented on how the care from the nursing staff and allied health professionals was ‘superb’, ‘exemplary ’and staff had a ‘great sense of humour’
In critical care we observed staff treating patients with kindness, warmth and emotional intelligence.

However:

In critical care the patients’ diaries were not being seen as belonging to the patient and were not being given to all patients or their relatives when they left the unit.

Responsive

Overall, improvements were required to ensure that services within the hospital were responsive to patients’ needs. It was rated inadequate in urgent and emergency care and medical care, and requires improvement in surgery and critical care.
There was no sense of urgency to respond and promote discharge to initiate flow through the emergency department to the rest of the hospital to reduce crowding in the emergency department. The bed management meetings were not dynamic in ensuring flow of discharges and admissions were acted on by the wider trust and not all required staff attended.
The emergency department was the single point of entry to the hospital for GP expected patients. There were no direct GP admission pathways in place and this further impacted on crowding in the emergency department on a regular basis.
Lack of timely access to a specialist senior doctor to review patients overnight in the emergency department was at times leading to delays in patient admission to wards.
Patients were not able to responsively access the care they needed. The trust did not consistently admit patients within 4 to 12 hours. This meant patients were in the emergency department longer, up to 20 hours and the department was much busier as a result.
Patient flow within the hospital affected theatre utilisation and cancellation rates. The ambulatory emergency care unit and discharge lounge were underutilised and the medical assessment unit was ineffectively used.
Medical patients were being cared for on surgical wards. The trust seemed unable to rectify this position and ensure patients received care on the appropriate ward for their speciality.
The trust does not separately measure the time to initial assessment for ambulance cases; this was included in the overall time to initial assessment in the emergency department. The trust consistently performed within the target for the latest 12 months. There had been a recent increase in patients leaving the department without being seen.
The hospital performed worse than the England average for length of stay in general medicine and surgery. The average length of stay for the trust was 10.1 days compared to the England average 3.6 days for medical patients and for surgery it was 3 days for elective patients, compared to 3.3 days for the England average. For surgical non-elective patients, the average length of stay was 6.3 days, compared to 5.1 days for the England average.
Too many patients were delayed in their discharge from critical care to a ward. These delays were worse than the national average. Some patients were discharged onto wards at night as a bed had become available, when night time discharge was recognised as less than optimal for patient’s wellbeing and mortality

However:

Despite the pressures and capacity issues the emergency department took account of patients’ specific needs. Individual care needs and adjustments were put in place.
Dementia was well considered across wards and units and patients were identified using a ‘forget me not’ magnet. There was an older people’s mental health liaison nurse who provided support for patients living with dementia. Staff were positive about this role and felt staff and patients were well supported.
The trust also employed a complex needs sister and a strategic lead for learning disability services. Staff notified these staff when a person with a learning disability was admitted and the strategic lead would then follow up the patient either in hospital or through discharge.
The management of meals and support provided to patients during a meal time on Kewstoke ward (care of the elderly) was responsive, where patient individual needs were central.
The dietetic department had expanded menu choices for those patients on a textured diet and had provided patients with their own specific modified menu so they could specify their own meal choices.

Well led

Well led was rated as requires improvement overall. It was rated as inadequate in urgent and emergency care, requires improvement in medicine and older people and good in surgery and critical care.
There was no visible strategy for securing permanent clinical leadership for medical staff within the emergency department.
The governance and management systems in place to review the risks, quality and safety of the service were reviewed regularly but have not effected any changes to the circumstances of the emergency department.
Staff in the emergency department told us their views were not considered and they did not feel involved in how decisions about their department were made. There was poor cooperation between levels and conflict between medical teams on the wards.
Arrangements were not robust for managing risks with lack of assurance these were managed timely and effectively. Audit processes had limited follow through of actions and findings were not widely shared at directorate level or at ward level.
In critical care we found a lack of multidisciplinary approach to leadership with medical staff not in regular attendance at governance meetings.
Leadership engagement with speciality mortality reviews did not support learning to improve patient outcomes in some services.

However:

In the critical care unit there were good assurance frameworks to demonstrate how the quality and safety of care was reviewed and understood, with a good culture of staff and patient involvement.
There was strong visible leadership within the surgical directorate and a good culture of team working. All the staff worked together to assess and plan ongoing care and treatment in a timely way.
There was a positive culture amongst staff within medical wards and units. Staff felt a sense of team work and worked hard together with a priority to provide safe and compassionate care to patients.
A crowding dashboard plus action cards had developed and was available in the department for staff to know if the level of escalation due to crowding had been reached. This tool had no link to the OPEL tool to escalate for wider action.
Leadership in the theatre departments was recognised by staff as strong leading to changes to the safety and the culture of theatres.

We saw several areas of good practice including:

The oncology and haematology department demonstrated outstanding practice with the way they assessed patient risk. Patients with a risk of neutropenic sepsis were easily identifiable through the use of a yellow jacket placed on patient notes.
Patients living with dementia were situated in the bays or side rooms that were most visible to the nursing station. Staff who provided enhanced supervision to these patients were wearing yellow tabards and were easily identifiable. Staff were allocated to a patient or a group of patients in a bay and were not to be removed unless another staff member had taken over from them. We saw the hospitals own ‘This is me’ booklet in the notes of a patient living with dementia. This booklet had been completed by a relative of the patient and explained the patient in detail, what they liked to be called what they liked to do, what was their favourite food.

Importantly, the trust must:

Ensure that there are sufficient numbers of suitably qualified, competent, skilled and experienced doctors deployed within the hospital. This includes sufficient medical leadership within the emergency department and suitable levels of staff to ensure the corridor is safely staffed.
Take action to ensure that there are sufficient medical staff with sufficient skills in advanced paediatric life support in the emergency department.
Take action to ensure that medicine systems in the emergency department are safe for controlled drugs including signature list for agency nursing staff and locum doctors, to cross reference who had prescribed and administered medicines.
Take action to ensure that systems are in place to ensure patient flow through the hospital was responsive.
Ensure patients are being admitted promptly once the decision to admit has been made. Take action to ensure that safety checks in the emergency department are completed.
Take action to ensure that patients are cared for in a safe environment in the emergency department.
Review the medical staffing and ensure safe levels of medical cover and support to juniors on the medical wards in evenings and weekends.
Review the use of locum consultants and take action to ensure medical staffing is not vulnerable through recruitment of permanent consultant staff.
Be assured junior medical staff are being provided with appropriate support and are competent in their roles.
Ensure safe nursing cover is provided on Cheddar ward and agency usage is kept to a minimum.
Take action to mitigate risks included on the risk registers effectively, reviewing regularly and managing those risks identified on a timely basis to ensure safety to staff or patients is not compromised.
Manage quality and performance and ensure sustained learning and improvements from audits.
Take action to continually maintain a clear path for evacuation in the event of a fire within the stroke unit by ensuring fire exits are not blocked.
Take action to ensure patient flow from the emergency department through the medical wards to timely discharge is effective and timely in meeting the needs of patents and ensuring good quality care and treatment.
Take action to address areas of concern and demonstrate patient outcomes monitored by the Summary Hospital – level Mortality Indicator (SHMI) are improved.
Improve the quality, attendance, accountability learning points and actions from mortality and morbidity reviews in all specialities.
Make sure the surgical directorate has an orthopaedic-geriatric service for pre and post-operative care.
Ensure all patients that had fractured neck of femurs were operated on in line with national guidelines and admitted to an orthopaedic ward within four hours.
Follow trust policy for the management of medicines, for example checking of controlled drugs, recording of medicine refrigerator temperatures and recording of signatures of agency nurses and locum doctors. (Accident and Emergency).
Review pharmacy staffing levels in order to meet service, clinical and medicines governance demands and achieve medicines related CQUINS and Carter model hospital indicators and therefore protect patient safety.
Ensure multidisciplinary input and a collective approach to the running of the critical care unit. The medical team leaders must ensure they meet regularly with the senior nursing leadership to provide a multi-professional approach and contribution to all aspects of running the unit, including governance and provision of quality care.
Address the poor access and flow of patients in critical care in order to reduce the delays to patients who are fit to leave the unit, reduce the risks of patients not having timely admittance, eliminate breaches in same-sex rules, stop the relocation to or delay of patients in the operating theatre recovery area, and reduce the number of patients who are transferred to a ward bed at night.
Produce mortality and morbidity reviews for critical care where there is accountability for learning and change, and a demonstration as to how this has improved practice and safety.
Review the provision for and quality of life support training in the trust to ensure there are a satisfactory number of staff with the right experience and training on duty at all times.

In addition the trust should:

Consider a clearer approach to reflect incident trends and ensure use of the hazard line identifies trends and is supported by consistent processes.
Ensure there is sufficient overview of the children’s waiting area in the emergency department to ensure children’s safety at all times.
Review the storage arrangements for patients own medicines and possessions when they were receiving care and treatment in the corridor of the emergency department.
Produce care pathways through the emergency department to support patient care. These should include frailty pathways for older people to ensure they receive timely care and treatment.
Consider actions to address professional working relationship breakdowns between doctors and established routines which had not been effectively addressed. These impacted on patients as early speciality review was delayed and patients had to wait in the emergency department.
Ensure national audit programmes and local audits effect change in practice.
Ensure emergency department staff are aware of the vision and strategy for the emergency department or the strategic development of the service.
Ensure the governance and management systems in place to review the risks, quality and safety of the emergency department service were reviewed regularly and effect changes to the department.
Ensure the risk registers for the hospital were accessible so staff can be aware of what was included on the risk register or how to raise issues for the risk register. This will enable risks to be addressed.
Reduce the in-use expiry date when glucagon injection is removed from refrigerated storage and record the date of opening of liquid medicines to ensure that these medicines are suitable for use. Ensure there is a robust system for checking expiry dates of medicines.
Review the storage arrangements for patients own medicines when they were receiving care and treatment in the corridor in accident and emergency.
Complete the medicines safety thermometer on all in-patient units on a monthly basis.
Audit the pharmacy service against the Royal Pharmaceutical Society standards for hospital pharmacy.
Review the medicines reconciliation service provided such that medicines are reconciled for patients in line with the NICE quality statement 120 and benchmarked requirements.
Ensure stroke patients are provided with optimum care in an environment which is conducive to improve their outcomes and meet their individual needs.
Review length of stay data and act to reduce this in line with national recommendations.
Review the environment regularly to ensure safety is not compromised for patients. During our inspection we identified broken window restrictors and fire extinguishers which were not secured to walls.
Review provision of seven day services to improve access to support at weekends and overnight.
Educate staff on the duty of candour so it is used consistently across the medical service.
Provide regular appraisals and clinical supervision to all staff to ensure they are appropriately supported and competent in their job role in medicine and the emergency department.
Remind staff of the procedures to follow in the event of a major incident and schedule regular practice.
Ensure the discharge lounge has appropriate arrangements for nursing support within escalation extended hours when the day case unit is not open.
Review the ward clerk staffing arrangements and extra resources available to ensure wards are appropriately supported for non-clinical duties.
Maintain a record through minutes of weekly medical meetings in the stroke and care of the elderly specialisms to discuss best practice for patients.
Remind staff of the importance to find the previous weight of a patient to enable them to identify weight changes at admission and comply with the malnutrition universal screening tool (MUST) guidelines.
Improve mandatory training attendance rates across the surgical directorate.
Improve compliance with completing the venous thromboembolism or blood clots (VTE) assessment tool.
Review the storage of equipment in the day case unit clean utility room.
Review length of stay for emergency and elective surgery patients so it is in line with the England average.
Make sure complaints are documented at senior level as being handled in line with policy.
Consider adding sepsis screening to the performance assurance framework, to continually audit sepsis recognition and treatment and monitor sepsis training.
Review supernumerary nursing cover in critical care to address the Faculty of Intensive Care Medicine core standard for safe supernumerary levels.
Make sure medical staff working in critical care have completed the update of their mandatory training.
Ensure medical records in critical care clearly state who has created the record and who has attended ward rounds.
Ensure all staff in critical care are aware of the difficult airways trolley.
Ensure all equipment checks in critical care are performed and recorded when required.
Review patient records to ensure the time a decision is taken to admit a patient to critical care is recorded and captured for audit work.
Make sure any medicines not given to a patient in critical care have the reasons recorded on the prescription charts.
Review the time taken with ward rounds in critical care and ensure this does not delay any requests for tests or procedures for patients while the round continues.
Be assured that nursing staff in critical care providing direct patient care are at the right level of qualification.
Review the provision of physiotherapy in critical care, which was not meeting best practice guidance. Also, review NICE guidance around rehabilitation and physiotherapy prescriptions.
Develop a valid programme of audit for the medical teams in critical care in accordance with an audit calendar and suitable programme for critical care.
Review how to address the lack of a clinical nurse educator role in critical care.
Review the critical care risk register at a multidisciplinary critical care meeting.
Ensure all staff in critical care have appropriate knowledge of Deprivation of Liberty Safeguards.
Ensure the reports of the Intensive Care National Audit and Research Centre are received when they are available, and discussed at clinical governance reviews.
Ensure any patient diary used with longer-stay patients is recognised as the property of the patient and returned to them or their relative when the patient is discharged from the critical care unit.

Professor Sir Mike Richards

Chief Inspector of Hospitals

We inspected the emergency department, medical and surgical wards and the critical care provision on the high care unit at Weston General Hospital as a result of concerning information regarding medical staffing which we had received following our inspection in May and June 2015. Our inspection took place on 17 and 18 August 2015.

We spoke with 33 junior doctors (both foundation year one and two), 8 middle grade doctors and registrars and 3 consultants. In addition we attended a divisional feedback session, led by a divisional director and attended by 18 junior doctors. We also spoke with nursing staff and the out of hour’s coordinator. We interviewed the chief executive, medical director and director of nursing.

The focus of our inspection was on the medical staffing in the trust and also the support and supervision provided to junior doctors.

The trust is not a foundation trust. At the time of our inspection the trust was subject to a transaction process, in which Taunton and Somerset NHS Foundation Trust was the preferred acquirer. This was at the Trust Development Authority’s Gateway 2.

Our key findings were as follows:

The numbers of consultants and middle grade doctors/registrars employed by the trust required improvement to ensure the sustainability of the service. There were a large number of vacancies in consultant and registrar/middle grade doctor posts within the trust. We saw that shifts were covered through staff undertaking additional shifts and by locums. In addition different approaches to medical staffing rotas had been employed, with consultants “acting down” to provide additional support to junior staff.
The trust had set up a “sustainability board” with partners and key personnel from other NHS trusts in the locale, to work together to gain additional staffing within the hospital. However, at the time of our inspection no additional consultants or registrars had been engaged through the sustainability board to provide services at the trust. Areas of concern were being highlighted and discussions were underway about how other trusts could provide support. Progress was being made in one particular area.
The trust was developing “metrics” regarding medical staffing at the time of our inspection in order to provide assurance regarding medical staffing numbers. However, it was not clear how the numbers of doctors which made up the staffing establishment had been determined.
We found that the trust had taken action following our inspection to improve the induction delivered to junior doctors joining the trust as a result of feedback in the GMC survey of junior doctors in 2015. A new cohort of doctors started work at the trust at the beginning of August 2015. All of the junior doctors we spoke with were positive about the induction they had received. Some told us that it had exceeded their expectations, following information they had received from junior doctors who had been at the trust in the past, others told us that it had been better than that which colleagues had had at other trusts. All reported it being a welcoming and friendly hospital. Formal feedback collected by the trust on the induction was also seen to be positive.
Junior doctors reported that they felt supported in their role and that they had been encouraged to ask for help and support when required. Some junior doctors said that some locums were more supportive than others.
Most junior doctors reported that they did not have to undertake tasks that they felt ill prepared or competent to carry out unsupervised. However, one junior doctor described having been told to “just get on” with a legal administrative task which they had not carried out before. Following our inspection the trust undertook an investigation of this incident.
A new director of medical education had been appointed although they had not started in their role at the time of our inspection. Additional support for the medical director had also been sought and was being finalised at the time of our inspection.
We saw there were formal teaching programmes in place for junior doctors across the trust. Cover was provided for junior doctors to attend. One junior doctor in the emergency department described being part time which meant several training sessions fell on their days off. They had raised this with the emergency department rota coordinator and had been told they were looking at ways to address this. The number of junior doctors on the rota in the emergency department also made release for study leave to attend conferences etc. difficult as there was not additional capacity to cover shifts. However, this was not reported in other areas of the hospital.
Junior doctors told us of examples of where teaching had been provided by consultants and more senior doctors. We observed teaching ongoing during our inspection.
All core surgical trainee posts had been withdrawn by the Deanery (due to a national reduction in the number of surgical trainees) and this had impacted on the capacity of the remainder of the surgical team. The trust confirmed they were addressing the capacity gaps as part of their ongoing staffing review and revision, and posts had been filled by locums and clinical fellows. Concern was expressed that the middle tier of doctors was being eroded which would remove the bridge between consultants and junior doctors. The shortage of substantive registrars created pressure for the team with staff feeling isolated and unable to pursue training opportunities. The trust told us there would be no change in the number of middle tier doctors and that two substantive registrar posts would be filled in October 2015.
There were 975 incidents reported between 5 June 2015 and 25 August 2015 relating to the areas of the hospital we inspected. Of these only 6 related to medical staffing.
The trust had implemented a new hazard reporting telephone line, for junior doctors to report concerns. This had resulted in an increase in reporting of concerns, incidents and hazards by this group of staff. All junior doctors we spoke with were aware of the reporting line.
There were a large number of patients who were described as medically fit for discharge within the hospital, who were waiting for packages of care within the community. This had an impact on the workloads of junior doctors. An action being taken was to work with partners to reduce the number of patients who were medically fit for discharge within the hospital, through the opening of a new facility. However, although an urgent priority, this had not occurred at the time of our inspection, despite actions from the trust to pursue this.

There were areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

Ensure that there are suitable numbers of doctors to ensure that a sustainable service is maintained.

In addition the trust should:

Continue to work with partners to ensure that patients who are medically fit for discharge are provided with care in an appropriate setting.
Continue to provide effective support, training and supervision to junior doctors within the trust.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Weston Area Health NHS Trust provides acute hospital services and specialist community children’s services to a 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.

It has three locations that are registered with the Care Quality Commission. These are Weston General Hospital which has 265 beds, The Barn in Clevedon and Drove House which both provide special children’s services.

At the time of our inspection the trust was subject to a transaction process, in which Taunton and Somerset NHS Foundation Trust was the preferred acquirer. This was at the Trust Development Authority’s Gateway 2.

We inspected this trust as part of our in-depth hospital inspection programme. The trust was selected as it is an example of a moderate risk trust according to our new intelligent monitoring model. Our inspection was carried out in two parts: the announced visit, which took place on the 19-22 May 2015, and the unannounced visits, which took place on 30 May and 5 June 2015.

We judged that the hospital overall required improvement. There were serious concerns with respect to safety within urgent and emergency care services and medical services. Throughout the hospital we saw staff providing care and treatment to patients in a caring and compassionate manner. The service for children and young people was outstanding overall and in particular with respect to the caring and responsive approach of staff.

Our key findings were as follows:

Safe:

Overall we rated the safety in the hospital as inadequate. There were serious concerns with respect to safety within urgent and emergency care services and medical services were also rated as inadequate. Safety within surgery services and critical care required improvement and in all other areas was rated as good.
Within the emergency department we found that at times when there were a higher number of people attending the emergency department, patients were not always assessed or prioritised in a timely manner. This meant they were not protected from the risk of avoidable harm. Whilst they were waiting in the corridor to be admitted to the department (for sometimes longer than an hour) patients were not adequately monitored by hospital staff, although ambulance staff were with them. There was no initial assessment on arrival to determine patients’ priority in relation to others waiting and those already in the department. Patients did not receive assessment in line with College of Emergency Medicine guidance. We observed that under normal conditions patients were assessed within College of Emergency Medicine guidance.
Self-presenting patients were not always assessed within 15 minutes in accordance with College of Emergency Medicine guidance. This meant that staff were not able to promptly identify or rule out serious or life-threatening conditions and prioritise patients accordingly.
We wrote to the provider to inform them of these concerns and required them to inform us of the action which they would be taking to rectify these issues. The response that we received showed that the trust had taken urgent action to deal with the risks identified.
Medical staffing within the hospital was a concern, particularly within medical services, surgical services and urgent and emergency care. There was a significant deficit in the number of consultants against the funded establishment, which resulted in unsustainable consultant rotas and reduced support for junior doctors. Junior doctors within medical and surgical services reported that they were undertaking tasks, unsupervised, for which they felt ill prepared or competent to perform.
In the area known as the high care unit on Harptree ward, there were insufficient numbers of appropriately qualified and skilled nurses deployed to care for high dependency patients. We raised this as a concern with the trust during our inspection and subsequently required, in writing, additional evidence to demonstrate what had been put in place to ensure that patients were not at the risk of harm. We received information which demonstrated that the trust had taken action to resolve the immediate concerns raised.
Although incident reporting was slightly above the England average, we found that feedback to staff about incidents reported often did not occur. This meant that staff, particularly medical staff, were not encouraged to report incidents. Some junior doctors reported they had been discouraged from reporting due to the negative response of some consultants. Reporting of incidents by junior doctors was low. The trust had identified that feedback on incidents was an area which required improvement and they were reviewing processes and updating the electronic reporting system to enable improvements. In some services, learning or improvements made as a result of incidents were not monitored or documented.
Nursing staffing was mostly safe in numeric terms, although there was a reliance on bank and agency staff to ensure that shifts were covered.
The trust had the lowest midwife to birth ratio in the country although midwives provided antenatal and postnatal support to approximately 1,500 women a year. All women were provided with one-to-one care when in labour. The supervisor of midwives to midwife ratio was above (worse than) the recommended level of 1:15. However, the trust had recruitment in place to improve this number.
The hospital was clean, despite some areas requiring refurbishment. Refurbishment of the theatre department was ongoing at the time of our inspection. Hand hygiene was seen to be good, with staff washing their hands, using alcohol gel as appropriate and observing the “bare below the elbows” policy. Most areas of the hospital had achieved the 95% compliance rate with infection control audits and those which had not were showing an improvement over time. Despite this, there had been a number of outbreaks of Norovirus in the hospital, which was attributed to a high prevalence within the community. There had been a higher number than expected cases of Clostridium difficile in the hospital in 2014-15, although this had reduced towards the end of the year and at the time of our inspection the trust had not had a case in 90 days.
There was a high incidence of pressure ulcers within the hospital, although the trend had decreased by 20% over the year prior to our inspection. The trust had been actively working to reduce the incidence of pressure ulcers. There were also improved rates of harm-free care within the hospital at the time of our inspection.
There were two never events in the hospital in the 12 months prior to our inspection. We identified a third never event took place in our review of information provided to us. This had not been reported as such. We asked the trust to look into this with the North Somerset Clinical Commissioning Group.
There were concerns regarding the audit of the use of the World Health Organisation surgical safety checklist. There was no policy or protocol regarding the carrying out of the audit. Within main theatres, the audit was not carried out adequately and there was not consistent improvement as a result of the audit. Despite this we observed good practice with adherence to the checklist protocol. There were concerns, however, regarding the debrief (which was not audited) where full attendance of staff was required but at the time of our inspection, this occurred only 78% of the time.
Staff were aware of their obligations under the new Duty of Candour regulation which, from November 2014, required organisations to inform and apologise to all relevant parties about specific patient safety incidents. We noted that this had not been applied in one instance where it should have been.
Safeguarding processes were clear throughout the hospital, including in services for children and young people. Training in safeguarding in most areas was below the compliance rate of 90% set by the trust. Staff training on the children’s ward was however, above the compliance rate.

Effective

The hospital overall required improvement in the effectiveness of services.
There was a comprehensive programme of nursing audit in the hospital.
Although in most areas there was a programme of clinical audit, there was no evidence that actions had been followed-up, the details of learning identified or that this had been disseminated. Within medical services there was limited evidence that patient outcomes were measured or monitored or that care and treatment was provided in line with evidence-based guidance or best practice.
Within maternity and gynaecology services; children and young people’s services and end of life care, there was evidence that care was provided in line with best practice.
There was good feedback about the provision of training for nursing staff. However, the support, training and supervision of junior doctors was reported to be poor. This was supported by the director of medical education in the trust. The General Medical Council survey of junior doctors in 2014 also confirmed these concerns and the results of the survey for 2015 (released the week following our inspection) were worse than for 2014.
Patients’ length of stay was higher than the England average within surgery and critical care, due to difficulties with discharging patients from the hospital, although in most medical specialities it was better than the England average.
Most patients within the hospital reported that pain relief was provided promptly when requested. However, there was no dedicated pain management team in critical care.

Caring

Patients and relatives throughout the hospital reported that staff were compassionate and caring. Within services for children and young people we judged that caring was outstanding.
Feedback from patients was overwhelmingly positive. Friends and Family tests throughout the hospital showed mostly high levels of patient satisfaction.
Patients said they were kept informed about their condition and treatment and we observed all staff speaking with patients in a dignified manner, using clear language.
Patients and those close to them were provided with support to help them cope emotionally with their care, treatment or condition.
We saw that patients’ privacy and dignity was maintained.

Responsive

Overall the hospital needed to improve in its responsiveness to patients’ needs.
Bed occupancy within the hospital was high and bed capacity and patient flow were a constant challenge. This had impacted on the emergency department where the trust was consistently failing to meet the national standard which requires 95% of patients to be discharged, admitted or transferred within four hours of arrival.
There were occasions where patients at the end of their life were moved between wards to accommodate new admissions and there were occasions where a side room could not be provided to a patient at the end of their life.
There were long delays in discharging patients at the end of their life to their preferred place of dying because of delays in obtaining ongoing packages of care within the community. Staff in the hospital completed rapid discharge documentation quickly.
Patients in the emergency department regularly queued in the corridor because there were insufficient cubicles in the department. This impacted on patient safety, comfort, privacy and dignity. Actions were being taken to improve patient flow within the emergency department, which seemed to work well during the day. However, out of hours staff did not recognise the risk posed to patients in the corridor.
All expected admissions to the hospital were referred through the emergency department which increased pressure on the department.
Patients did not always receive care and treatment on the most appropriate ward and some patients were moved several times during their inpatient stay, sometimes at night.
Patients were not discharged from medical, surgical or critical care wards and units in a timely manner, partly due to staffing issues and partly due to with difficulties in arranging suitable care packages in the community.
Premises were not always fit for purpose. Accommodation in the ambulatory emergency care unit and the medical day case unit were not appropriately laid out or equipped to ensure patient’s comfort, privacy and dignity.
Within outpatients and diagnostic imaging, referral to treatment times were meeting national targets and monitored regularly. If delays for appointments occurred, extra clinics were arranged in the evenings or at weekends. However, there were high levels of cancellation of outpatient appointments which were not monitored by the department.
There were no barriers to making a complaint. However, in a number of areas, there was little evidence of learning being shared or improvements made as a result of complaints being monitored. A notable exception was within services for children and young people.
Services for children and young were tailored to meet patients’ individual needs. They were delivered in a flexible way and at a time that suited the child or young person and their parents.

Well led

Nursing leadership within the hospital was strong. All staff we spoke with referred to the visibility and support provided by the nursing leadership.
In contrast, medical leadership within the hospital was poor. There was significant discontent expressed by junior doctors and a lack of confidence in medical leaders to either recognise or resolve their concerns. In medical services the culture did not support openness and challenge.
Governance in a number of areas within the hospital required improvement. There were improvements in risk management within some areas of the trust. However, risk registers were not always used proactively. There was visibility of the quality of nursing care throughout the hospital. However, data was lacking in some key areas, particularly within urgent and emergency care where there was a lack of visibility of the time to assessment of patients arriving in the department, for example. Within surgery, critical care and medical services, there was a lack of monitoring of improvements as a result of audits, incidents and complaints. In some cases these were not identified.
As a result of the transaction process, there was no long term vision. However, there was a focus on maintaining safe and high quality care to patients which all staff we spoke with were passionate about. The organisational values were known by some staff but not all.
Within services for maternity and gynaecology, children and young people, end of life care and outpatients there was evidence of positive cultures, innovations and actions taken to make service improvements.
Operating theatres were not running efficiently and were under-utilised. There was insufficient planning to avoid last minute changes and competing priorities.

We saw several areas of outstanding practice including:

There was an outstanding example of caring shown to a patient with a learning disability who was coming into the day-surgery unit for a procedure. One of the staff had contacted the patient’s care home and discussed the best way to manage the appointment for the patient. The arrangements were then made to reduce the anxieties of the patient, and allow one of the main carers to be with the patient as much as possible during the procedure. An ‘easy read’ booklet about coming into hospital was send to the care home to go through with the patient in advance of their visit. This showed a good depth of knowledge and sensitivity for people with different needs.
In medical services there were regular and effective multidisciplinary board rounds which ensured a coordinated and focussed approach to care planning, including discharge planning.
In medical services, nurse leadership was frequently praised by nursing and medical staff. Nurse leaders were described as visible, approachable and focussed on improving the quality and safety of patient care.
There was an outstanding staff newsletter produced each month. It included ‘celebration of success awards’ which were running for their second year. There were messages from public bodies, such as Public Health England, awards and recognition for staff and wards, updates on new staff, messages from patients, training and policy updates, and charity news and updates.
The patient risk midwife was responsible for the majority of governance and quality measures and had outstanding processes in place. This person demonstrated a clear oversight of all current issues. We saw there were thorough processes and audit trails in place for risk, governance and quality information. We saw evidence of how information was thoroughly interrogated for service and safety improvements.
There was outstanding care for children, young people and their families.
The outpatients’ manager responded and developed improvements as a result of incidents that originated outside the outpatients department. For example, problems had been caused by plaster casts that had been applied in other wards and departments. In response, the senior plaster technician in the orthopaedic clinic had devised a teaching programme to improve the skills of other clinical staff. This had been rolled out across the hospital and no further problems had occurred.
Following manual handling training in 2014/15 medical records staff had become concerned about the weight of boxes of records that they needed to lift. As a result, scales had been installed throughout the hospital to ensure that no boxes heavier than 11kg were lifted by staff. One of the medical records managers told us there had been a decrease in musculo-skeletal injuries since this change.
At the beginning of 2015 the imaging department had gained full accreditation with the Imaging Services Accreditation Scheme (ISAS). This is a patient-focussed assessment that is designed to ensure that patients consistently receive high quality services. The ISAS website states that ,as of May 2015, only 20 departments in the UK had achieved this accreditation

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

Importantly, the trust must:

Take action to improve medical staffing levels and skill mix in the emergency division (particularly within medical services) to ensure that people receive safe care and treatment at all times.
Ensure that junior medical staff in the emergency division (particularly within medical services) are appropriately supported, supervised and trained to ensure that they are competent to fulfil their role.
Ensure that the ambulatory emergency care unit and medical day case unit are appropriately staffed and equipped at all times.
Ensure that patients who attend the ambulatory emergency care and medical day case units are accommodated in areas which are fit for purpose and ensure their comfort, privacy and dignity.
Continue to take steps to reduce the incidence of avoidable harm as result of pressure ulcers, falls and medication incidents.
Ensure that patients arriving by ambulance are fully monitored and assessed for priority when in the corridor awaiting admission to the department.
All patients receive timely assessment in line with College of Emergency Medicine guidance to ensure that they receive suitable and timely treatment.
Ensure that all staff are aware of and work to standard operating procedures relating to the safer management of controlled drugs.
Ensure that there are suitable numbers of staff with the qualifications, skills and experience to meet the needs of patients within the high care unit.
The audit and use of the whole range of the World Health Organisation surgical safety checklists must be improved and evidence provided to show it is being followed at all times. The hospital must ensure there is approval at board level for how the checklist is being used and audited.
Competency tests around the use of equipment in operating theatres must be improved to demonstrate it is vigorous. Considering there had been a high rate of medicine incidents, competency training must be introduced for medicines’ management. There must be an approved protocol for how competency is assessed.
The main operating theatres must ensure the management of all used surgical instruments is such to be assured the risk of cross-contamination is eliminated.
The hospital must ensure the medical cover in surgery services, out-of-hours, and specifically at night, is safe and the staff on duty meet the requirements of the out-of-hours policy.
The number of discrepancies in prescriptions in surgery services must be addressed and errors eliminated.
The hospital must ensure patient confidential records are secured and stored in such a way as they cannot be seen or removed by unauthorised people.
Staff in surgery services must get up-to-date with their mandatory and statutory training and meet trust targets.
The hospital IT systems must be improved to enable staff to extract and be able to use data about all aspects of theatre and surgery services.
As with most NHS hospitals, the hospital must improve the access and flow of patients in order to reduce delays from theatre for patients being admitted to wards, enable patients to be admitted when they needed to be, and improve outcomes for patients.
The governance of the surgery service must improve so there is a clear process for assessing and monitoring the safety, effectiveness and responsiveness of the service. The governance team must be able to demonstrate continuous learning, improvements and changes to practice from reviews of incidents, appropriate use of the risk register, mortality and morbidity reviews, formal clinical audits, complaints, formal feedback to staff, and using reliable data and information.
As with most NHS hospitals, the hospital must improve the access and flow of patients in order to reduce delays from critical care for patients being admitted to wards; reduce the unacceptable number of discharges at night; enable patients to be admitted when they needed to be; ensure patients were not discharged too early in their care; and improve outcomes for patients. The full consideration of critical care must be taken into account in hospital escalation plans and staff in the unit closely involved with day-to-day strategic planning.
The governance of the critical care service must improve so there is a clear process for assessing and monitoring the safety, effectiveness and responsiveness of the service. The governance team must be able to demonstrate continuous learning, improvements and changes to practice from reviews of incidents, appropriate use and review of the risk register, mortality and morbidity reviews (including overarching mortality ratios), formal structured clinical audits, complaints, formal feedback to and from staff, and useful feedback from people who use the service.

Staff in the critical care service must get up-to-date with their mandatory and statutory training and meet trust targets.

In addition the trust should:

Ensure it follows the Duty of Candour regulations at all times.
Take steps to increase staffing levels in physiotherapy, occupational therapy, speech and language therapy and pharmacy so that patients’ care and treatment and discharge are not delayed.
Ensure root cause analysis reports in surgery services identify, acknowledge and act upon all causal factors identified in the investigation of the incident.
Improve the utilisation and organisation of the operating theatres to make the services more efficient for patients, staff and hospital revenue.
Ensure that surgical-site infection data is captured internally and provided in governance reports.
Address the security of operating theatre areas to avoid unauthorised people getting access to areas that otherwise should be secure.
Ensure that trolleys for resuscitation equipment in surgery areas are secured in such a way to highlight to staff if they had been opened or used between daily checks.
Ensure there is an appropriate and safe level of equipment in main theatre operating areas, including the recovery room.
Take steps to improve record keeping. In particular, particular nursing staff on Uphill Ward should ensure that they consistently document when they re-position patients and check cannula sites. Medical staff in medical services should ensure that DNACPR records clearly indicate the timeframe for the decision documented. The medical staff in critical care should review their entry to patients’ notes and ensure they provide a comprehensive, contemporaneous record to both records used on the unit and those used for patient discharge to the wards.
Ensure that patients’ notes are filed securely so that they do not become lost or put in the wrong place.
Ensure that patients on surgery wards should have all their repositioning in beds or chairs attended to when it is required so that pressure ulcer damage reduced and safely managed.
Establish a dedicated pain team in accordance with the Royal College of Anaesthetist standards.
Review staffing levels and the use of bank and agency staff and look for ways to reduce the impact this is having on patients and substantive staff.
Review ward round arrangements on surgery wards to reduce this to a manageable and safe level.
Review the operational policy for theatre to ensure that it follows the latest Royal College or other relevant guidance.
Review hip-fracture surgery for patients to increase the number of procedures meeting the best-practice tariffs.
Improve the provision of in-house training and development for surgery staff, particularly in theatres.
Review the risk register in surgery services so it is a true and current reflection of specific risks within the service. The document should be proactive and discussed as a standing agenda item in governance meetings so all staff are aware of the risks within it and their responsibilities for reducing or mitigating them.
Review local management arrangements on the critical care unit. The unit should be run by all staff in a collective approach, so each can contribute to the management of the service and support one another. There should be a multidisciplinary approach to the running of the unit in the same way as there is to the care and treatment of the patient.
Ensure the rota for the critical care consultants is sustainable in the longer term and review the cover by junior doctors against the guidance of the Faculty of Intensive Care Medicine Core Standards.
Review the critical care services risk register so it is a true and current reflection of specific risks within the service. This should include entries to describe where the unit does not meet the Faculty of Intensive Care Medicine Core Standards and the Department of Health building standards for critical care. The document should be proactive and discussed as a standing agenda item in governance meetings so all staff are aware of the risks within it and their responsibilities for reducing or mitigating them.
Ensure that trolleys for resuscitation equipment in critical care should be secured in such a way to highlight to staff if they had been opened or used between daily checks.
Review the provision of technical support for equipment cleaning, set-up and maintenance in critical care.
Review the process for critical care obtaining non-stock items from the pharmacy in order that the patient’s prescription drug chart does not need to leave the unit.
Improve pion of in-house training and development for critical care and ensure the guidelines of the Faculty of Intensive Care Medicine Core Standards around use of a clinical nurse educator are met.
Review staffing skill mix to ensure there is supernumerary cover by senior staff on duty at all times, including weekends.
Ensure the protocol used for applying Deprivation of Liberty Safeguards in critical care follows the provisions of the Mental Capacity Act (2005) and any deprivations would be applied with in line with the legal requirements of the Safeguards.
Review the use of some of the more recent developments in critical care support, such as the patient diary, follow-up clinic, and professional psychological for patients and their relatives.
Improve the provision for visitors to critical care and look at ways to improve the experience for families and friends.
Review the ratio of supervisor to midwives to ensure compliance with the recommended ratio of 1:15.
Ensure are be compliant with the trust’s mandatory training targets of 85%.
Ensure that midwives are compliant with the trust’s annual appraisal target of 85%.
Improve the uptake of the Friends and Family Test in all maternity areas to give more consistent and reliable data.

Professor Sir Mike Richards

Chief Inspector of Hospitals

This inspection was to check action had been taken to address three compliance actions issued when we inspected the hospital on 16-18 April 2013. These related to staffing levels, record keeping and medicines management. Additionally, we checked on patient care and welfare in response to recent concerns we had received.

We visited seven wards, the day surgery unit and the emergency department (ED). We spoke with 35 patients, nine relatives and 32 staff. We looked at 24 patient records.

The majority of patients spoken with told us they had no complaints about their care and some said they received 'Brilliant care'. An older patient in the ED said 'I've been looked after extremely well. I don't mind how long I stay here it's so good'.

Action had been taken to ensure the safe keeping of medicines although some further improvement was needed.

The hospital had been successful in recruiting a significant number of new nurses and a number of additional doctors. One patient said 'No problem, staffing levels are about right'. A patient who had previously been admitted to the hospital said 'Staffing is much better than 6 months ago'. A doctor said 'things seem to be in hand, nurse staffing has increased and they are trying to recruit more permanent senior doctors'. A ward sister said 'Staffing numbers have improved, the new nurses are brilliant and patients love them'.

We found significant improvements in the accuracy and completeness of patient records.

This inspection was to check that action had been taken to address the two warning notices issued when we last inspected the hospital on 16 ' 18 April 2013. These related to people not being treated with dignity and respect and people's care and welfare needs not being met. We also checked on the hospital's quality monitoring systems. The compliance actions issued at the time of the April inspection for three other areas of non-compliance will be followed up later in the year.

At this inspection we visited 11 wards and the emergency department. We spoke with 70 patients, three relatives and 19 staff. We looked at 36 patient records.

We found a significant improvement in the way patients were treated. Patients said 'Staff always pull the curtain around my bed when providing personal care and give me reassurance' and 'The staff are very respectful and always ask before they do anything'. We observed staff cared for people in a respectful and considerate manner.

Patients were happy with the care and treatment provided. Patients said 'The call bell, food and drinks are all put within my reach and they come quickly when I need them' and 'The care has been first class and I've been looked after really well'. Records confirmed that patients received appropriate and timely assessments and care was delivered in line with their individual care plans.

We found improved quality monitoring arrangements had been made in response to our previous inspection findings.

We carried out this inspection to follow up on two compliance actions from our last inspection on 20 August 2012 and in response to information of concern we had received.

We visited five of the hospital's wards, the discharge lounge and the hospital's accident and emergency department. During the inspection we spoke with 36 patients, four relatives, 42 staff and senior trust management. We also looked at 22 inpatient records and 37 patient medicine administration records.

We found patient's privacy and dignity were not always respected. One patient said 'The other night I wanted to use the toilet. It took an hour before anyone got back to me and by then it was too late. That was very embarrassing'.

The welfare and safety of patients was not always ensured. One patient admitted in the early hours of the morning told us 'I was frozen there were not enough clothes on the bed. I didn't know where the call bell was'. Patients and staff in the emergency department told us the department was often over stretched.

Medicines were safely administered but appropriate arrangements were not in place for the safe keeping of medicines.

Effective recruitment and selection processes were in place.

Staff in all areas visited told us they were often short staffed. One patient said 'Staff have too many patients to see too. I feel guilty to ring the bell for support'.

Patient records were poorly maintained.

We last carried out a review of this essential standard in March 2012 and issued a compliance action requiring the trust to make improvements. This inspection was a follow up to check that improvements had been made.

We discussed progress with the trust management and with representatives from external health and social care organisations. We found that improvements had been made in cooperation and coordination of care between the hospital, community services and other providers. We reviewed patient records and had discussions with patients and hospital staff. At this inspection we found that suitable hospital discharge arrangements were in place.

People waiting in the hospital's discharge lounge told us they were happy with the care provided and the arrangements for their discharge from hospital. One patient said 'I have been waiting for a couple of hours for my tablets and paperwork but I don't mind. I've been seen by two doctors and the nurses and they all said I was OK to go'. Another patient said 'They've all been very good. They offered me a hospital bed for the night but I preferred to go home and come back again today for tests'. A relative told us 'I can't fault it here. Staff were very good at explaining everything to us'. People told us that checks had been made to ensure that hospital prescribed medication did not react with their own medication. In other cases special equipment had been ordered to enable people to be discharged home.

We visited Weston General Hospital on 20 August 2012. On all of the wards we visited we heard conversations that were tailored to the individual needs of patients. Staff were compassionate, considerate and respectful in their delivery of care, providing care in a patient and calm manner.

One person told us that they had received treatment from a 'wonderful nurse' and she also said that on the previous day she had been given an 'outstanding' level of care.

All patients spoken with during our inspection said they felt safe and well looked after.

We saw that peoples privacy and dignity was not always maintained for example ward rounds and cleaning were still continuing throughout lunchtime. We saw that people were sometimes given tissue instead of hand wipes to wipe their hands prior to eating. We saw empty urine bottles on peoples bed side tables on two of the wards we visited. Following the inspection we were told that the urine bottles were clean and it was patient choice to keep them where they were.

On Harptree West we were told that staff raised their voices at night and were not always respectful of the need for sleep.

On all of the wards we visited we saw that the male and female patients were accommodated in different areas of the ward and there were separate male and female toilets and bathrooms.

People told us that the meals were generally good with drinks and snacks available at all times. However one patient said he was usually hungry around 10pm each night but was unwilling to ask for food as the staff were usually very busy caring for other patients.

We saw people being appropriately supported with their meals if necessary.

Patients and staff we spoke with told us that they felt there often were not enough staff. Patient comments included; staff were "hard pressed" and the staff 'work hard' but are often "slow to answer the bell". Staff comments included; 'not enough staff to meet needs of patients', too much to do', 'too stretched' and 'very rushed ' not good for patients or staff'.

People spoken with on two wards said they believed their records were kept up to date. One person knew he could see his care plan/patient record.

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that treatment for the termination of pregnancy was not commenced unless two certificated opinions from doctors had been obtained.

We did not directly involve patients using the hospital for the purposes of the review.

A number of issues have arisen recently following the discharge of some patients from Weston General Hospital, after a period of in-patient care. We found that the way in which the hospital staff communicates with families, community based health and social care professionals, is not always good enough, and impacts upon the care and welfare of their patients.

We have asked the trust to provide us with their improvement action plan, telling us how they will improve their discharge arrangements, to ensure that every person who leaves the hospital does so safely, and with the ongoing support they need.

We had concerns raised with us in respect of the way information is relayed to health and social care providers who are providing ongoing care to people after discharged from hospital. The specific concerns related to the following:

' A lack of sufficient information provided by nurses to care homes about the person's hospital stay

' Unclear instructions about medication regimes on doctors discharge summaries

' A lack of communication regarding the status of a person's skin upon discharge from hospital, and

For this reason we did a spot check on some patient's notes, with a focus on the discharge summaries completed by the medical staff, and transfer letters completed by the nursing staff. We also checked the information supplied about people's medicines.

We met with hospital managers to find out what they are doing about these issues and their plans for improvement.

When we visited the hospital we spoke with patients who were waiting in the discharge lounge prior to going home. They told us 'I am waiting for my tablets and letters', 'I have been given a letter for my doctor and my medicines. I know what to take and when' and 'I think the nurse said there were some things for me to take with me. I think they have put them in my bag. I am waiting for an ambulance to take me back to the nursing home'.

We spoke to staff working in the discharge lounge and they told us that patients may be waiting for their medicines or for transport to collect them. We were told that ambulance transport would not be arranged for patients until their medicines were ready.

In January 2011 we carried out a review of Weston General Hospital and we identified some areas where the hospital needed to make improvements. Following the review Weston Area health NHS Trust told us about the changes they intended to make. The purpose of this review was to visit the hospital to check on the improvements. The areas we were concerned about were:

Consent to care and treatment

Care and welfare of people who use services

Records

We spoke to people using the hospital service when we carried out our review in January. At this visit we did not involve people who were using the service, as the way we checked the improvements was by looking at people's care records. We found that there had been significant improvements in how staff record consent and capacity issues. Monthly audits are in place and will be continued, in order to maintain full compliance.

We also found significant improvements in the completion of care plans, for people staying in the hospital.

The trust's audit arrangements of medical notes show a trend of improvement, however there are still shortfalls in respect of discharge information being sent out with people when they leave the hospital. The trust will continue to audit medical notes and we will follow this up to check their progress.

People told us that they were happy with the care and treatment they received. They were very complimentary about the staff saying that they were kept informed about their progress and what was happening. 'The standards of care and the carers are brilliant', 'my husband has problems with his speech and the nurses are so patient with him' and 'I can't fault the way the nurses are looking after my wife. They are always cheerful'.

People were generally very complimentary about the meals they were served. They are able to choose what they would like to eat as a range of different meals are offered.

People told us that they were well looked after, their care needs were met and the staff were kind to them. 'I feel safe', 'I am very satisfied' and 'the doctors and nurses are all very respectful and take time to explain things to me even though they are always very busy'.

People told us that the ward was cleaned regularly, and they made particular reference to the toilets and the bathrooms. They told us that the domestic staff worked hard and did a thorough job.

People told us that the wards were comfortable. 'The toilets are clean but there are not enough bathrooms. This means I sometimes have to wait until 11am to have a bath', 'The ward is calm' and 'Generally the ward is quiet at night but sometimes I have to use ear plugs so I can sleep'.

People told us that they knew how to make a complaint about their care and treatment, and felt able to voice their concerns. They told us 'I can not fault the way I have been looked after ', 'I have no complaints about my care but I have a number of observations. My wife has told me about an exit card I can complete when I go home' and 'I would ask to see the ward sister if I had reason to complain'.

This section was not completed for this inspection. More information about what we found during the inspection is available in the report below.

All Inspections

Deputy Chief Inspector of Hospitals (London and South), on behalf of the Chief Inspector of Hospitals

Professor Sir Mike Richards

Professor Sir Mike Richards

Chief Inspector of Hospitals

Professor Sir Mike Richards