Archived: Christchurch Hospital

Christchurch hospital is the smaller of two hospitals provided by The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust. The trust gained foundation status in 2005 and provides services, to a population of 550,000 in the Dorset, New Forest and south Wiltshire areas, which rises in the summer months due to an influx of visitors to the area.

We inspected the trust, Royal Bournemouth Hospital, and Christchurch Hospital as part of our comprehensive inspection programme.

Christchurch Hospital provides end of life care services including, the Macmillan Unit with 16 inpatients beds, a specialist palliative care centre and a community palliative care team. There are a range of outpatient clinics including children’s dermatology out patients, and an x-ray service. There is a large day hospital providing rehabilitation services.

We inspected two core services at Christchurch Hospital: end of life care; and outpatients and diagnostic imaging. We also inspected children’s outpatient dermatology service and detailed findings are within the Royal Bournemouth Hospital location report under children and young people’s core service.

No other services are provided at Christchurch Hospital.

We carried out an announced inspection visit to Christchurch Hospital 20 -22 October 2015. The inspection team included CQC inspectors, specialist palliative and end of life care nurse, speciality doctor in palliative medicine, consultant geriatrician, respiratory physician, physiotherapist, radiographer, paediatric nurse, and experts by experience.

We rated Christchurch Hospital as ‘good’ overall and good for providing safe, effective, caring responsive and well led end of life care services, and outpatient and diagnostics services.

Our key findings were as follows: 

Are services safe?

• There were reliable systems and processes in place to support the delivery of safe care and treatment.
• Staff were aware of their responsibilities to report incidents and there was evidence of learning from incidents.
• There were two never events in dermatology outpatients in the 12 months to April 2015, these had been thoroughly investigated with processes and practices changed as a result.
• In diagnostic imaging, staff were confident in reporting ionised radiation medical exposure (IR(ME)R) incidents and followed procedures to report incidents to the radiation protection team and the Care Quality Commission.
• The hospital site was undergoing a major re-development and refurbishment programme. Environmental risks had been assessed and mitigations put in place to ensure safety was not compromised.
• Patient clinical areas were visibly clean and staff followed infection control policy and practice.
• Records were well completed and generally stored securely.
• Staffing levels were adequate in all areas, with recent recruitment to meet additional demand on end of life care services. There were appropriate arrangements for out of hours cover.
• Staff had a good understanding of safeguarding adults and children. Safeguarding was given sufficient priority and staff took a proactive approach to the early identification of safeguarding concerns.
• Medicines were appropriately managed and stored in most areas, however oxygen was not stored in appropriate holders in the Macmillan Unit. Patient group directions (PGD), which allow trained non-prescribers to administer medicines without prescription, were mostly in date.
• Equipment was serviced, checked and stored appropriately.
• Mandatory training for staff in end of life care services was below target. Compliance with mandatory training was high for outpatient and diagnostic imaging services.
• Patients were assessed and monitored appropriately. In end of life care services there were arrangements to minimise risks to patients including falls, and pressure ulcers. Staff demonstrated a good understanding of the early identification of a deteriorating patient.
• Staff generally had a good understanding of the Duty of Candour and their roles and responsibilities in applying it to their everyday practice.

Are services effective?

• People’s care and treatment was planned and delivered in line with current evidence based practice. A new personalised end of life care plan was in use following the withdrawal of the Liverpool Care Pathway.
• There was evidence of National Institute for Health and Care Excellence (NICE) guidelines being adhered to in outpatients. Local audits were undertaken in outpatients and diagnostic imaging
• Patients had appropriate access to pain relief. Anticipatory end of life care medicines were appropriately prescribed for symptom control and patients were provided with pain management support.
• Patient nutritional needs were met, with dietetic support if required. The nutritional status of most patients was assessed prior to admission to the Macmillan unit. There were plans for assessment of all patients on admission.
• There was effective multidisciplinary working across the Christchurch hospital site and the Royal Bournemouth Hospital and continuity of care with GPs and community staff. Staff worked collaboratively to understand and meet the range and complexity of people’s needs.
• Most staff had received an annual appraisal although there had been some delays due to a change in the appraisal system in 2015. Staff felt able to access relevant training to update their clinical skills specific to their roles.
• Staff were appropriately qualified, with access to a comprehensive training programme for end of life care.
• Patients had access to seven-day services, as required.
• Most staff had a good understanding around consent procedures and there was good understanding of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards which ensures that decisions are made in patients’ best interests
• Most ‘do not attempt cardiopulmonary resuscitation (DNACPR) forms’ were appropriately completed.

Are services caring?

• Staff treated patients with compassion, kindness, dignity, and respect.
• Feedback from patients and their families was consistently positive for all services.
• The latest Friends and Family test results showed that 97% of patients completing the survey agreed that they would recommend the hospital to family and friends.
• Patients and their families were respected and valued as individuals and were empowered as partners in their care.
• Staff recognised when a patient required extra support to be able to be included in understanding their treatment plans.
• All staff demonstrated a commitment to providing compassionate care not only to patients but also to their families and post bereavement.
• Chaplains and staff provided emotional support to patients and relatives. A team of volunteers had been trained to provide additional support for patients receiving end of life care
• Outpatient department staff provided emotional support and used quiet rooms to speak with patients who had been given bad news.

Are services responsive?

• Services were planned and delivered in way which met the needs of patients, and the local population.
• There was an overarching development plan for the hospital site. This included refurbished facilities and development of existing services and working with partner organisations to create additional primary and social care services to meet the needs of the local population.
• There was good access to outpatient and diagnostics clinics, with Saturday clinics held for certain specialties. Patients told us that there was good access to appointments and at times which suited their needs. Patients reported clinics generally ran to time.
• From October 2014 to June 2015, the trust achieved or exceeded the referral-to-treatment (RTT) standard of 92% for patients waiting less than 18 weeks from referral to treatment (incomplete pathways) in every month.
• There were delayed discharges from the Macmillan Unit that were impacting on timely admission of patients, this was recognised and was being addressed at board level.
• Action was taken to meet the increasing number of referrals to the specialist palliative care community team
• Despite on-going building works in and around the hospital patients commented on the pleasant environment and the atmosphere within the hospital. The hospital was accessible for patients in wheelchairs.
• There was no signage available for patients who did not speak English as their first language and no information leaflets were available in any other languages. An interpreter service was available trust wide, which was booked once staff were aware of patient requirements.
• Service received very few complaints and concerns. Those that had been received had been resolved locally and informally and changes made as required. The Macmillan unit received many commendations.

Are services well led?

• The trust had an overarching strategy for the development of service at the Christchurch hospital site. Also staff were generally aware of the vision and values of the trust to be the most improved hospital in the UK by 2017 and to provide excellent care as they would expect for their families.
• The 2020 strategy for diagnostic imaging was being planned with staff engagement in moving the strategy forward.
• The end of life care strategy, based on achieving full compliance with national guidelines, was created in response to the inspection. Although it reflected much of the vision and ongoing work of the end of life steering group, it had not been subject to consultation or presented at trust board level.
• The services at the hospital were well led locally, staff felt supported and worked in an integrated way across teams and services. Staff in all areas told us their manager was visible and approachable and they felt well supported and valued.
• There were governance structures within the services and systems for identifying, assessing and managing risk, and monitoring quality and performance.
• There was an open culture and staff felt they could make suggestions to improve service for patients. Feedback was actively sought from patients. The day hospital held patient focus groups where patients and their representatives could put forward suggestions for changes and improvements to the service.
• The palliative medicine consultants and community specialist palliative care service were working to continually improve the quality of end of life care across the trust.
• Some staff felt distant from the Royal Bournemouth Hospital and reported a lack of visibility of the trust executive team at the Christchurch hospital site.

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

The trust should ensure:

• There is consultation on the overarching end of life strategy, with internal and external stakeholders.
• Where relevant, mental capacity assessments are completed on the DNACPR forms.
• All policies within end of life care service are reviewed and updated as planned.
• A formal clinical audit programme is put in place at the hospital.
• Staff appraisals are completed, to reach trust targets.
• Staff complete mandatory training, to reach trust target levels.
• Nutritional screening is completed for patients on admission to the Macmillan unit.
• Medical records are stored more securely, in locked trolleys and /or secure offices to prevent unauthorised access.
• Timeliness of communication between end of life care services and the district nursing team.
• Documentation of the efficacy of pain relief given to patient in end of life care.
• Monitoring of all a patients with a delayed discharge is reviewed.
• Oxygen cylinders stored in a location on the Macmillan unit where they are not a trip hazard.
• Review the processes in place for monitoring the fridge temperature in the mortuary.
• Improve the general decoration of the mortuary viewing room, if it continues to be used.
• Review notice boards throughout outpatient departments at Christchurch Hospital to ensure clear and consistent information is provided.
• Trust senior management are more visible at Christchurch Hospital.

Professor Sir Mike Richards

Chief Inspector of Hospitals