West Suffolk Hospital

The Care Quality Commission (CQC) carried out a comprehensive inspection between 8 and 10 March 2016. We also carried out an unannounced inspection on 23 March 2016. We carried out this comprehensive inspection as part of our regular inspection programme.

The West Suffolk Hospital site, in Bury St Edmunds, is where the majority of the services offered by West Suffolk NHSFT occur. The trust also offers outpatient and community services at Newmarket Community Hospital, Haverhill Health Centre, Thetford Healthy Living Centre, Stowmarket Health Centre, Sudbury Health Centre, Botesdale Health Clinic and Mildenhall Clinic.

During this inspection we inspected the trust’s sites at Bury St Edmunds and Newmarket Community Hospital. We did not inspect at the other locations as they only offer outpatient services at these sites. West Suffolk Hospital serves a population of approximately 275,000 people, over an area of roughly 600 square miles.

During this inspection it was evident that the trust had an established staff base that was proud to work at the hospital. Many staff had worked at this location for a long time. This meant that challenges were addressed quickly and efficiently. However, documentation of recorded actions was not consistent but this did not impact on the care of patients. The trust and its staff placed the patient at the centre of care provided and strove on a daily basis to enhance the patient experience of healthcare.

Our key findings were as follows:

• All staff were helpful, open and dynamic. They were aware of what good looks like and were striving to implement this in daily practice. Staff were proud to work at West Suffolk Hospital.
• Staff felt well supported by their managers and were impressed at the visibility of the chief executive.
• Feedback from patients, relatives and carers was extremely positive throughout the hospital and at the listening event.
• There were some excellent leaders in a number of areas, especially in the gynaecology and post-natal wards. The interim head of midwifery was providing good support to her team; however they would benefit from further support.
• Staff were overwhelmingly caring in delivering care to patients. We witnessed some examples of excellent compassion and all staff we met put patients at the center of the care provided.
• Many good ideas for improvement and innovation were from the junior, ward level staff.
• Staff awareness and understanding of the Mental Capacity Act and Deprivation of Liberty Safeguards was not consistent.
• Medical cover at night was not consistent and was not in line with good practice guidelines.
• In the maternity service there had been a previous bullying culture that was beginning to decline. However pockets of this still existed.
• Staff could not adequately explain the governance arrangements.
• Information governance and data protection within medical photography was not assured. Systems for audit and documentation records and consent were not embedded or monitored effectively.

We saw several areas of outstanding practice including:

• The porters’ display of respect for the transport of the deceased to the mortuary especially in respect of baby deaths.
• The virtual fracture team who were dedicated to ensuring diagnosis of fractures was not missed in the emergency department (ED).
• The receptionist in ED providing CPR to a collapsed patient and summoning immediate assistance.
• Two consultant pediatricians learnt hypnosis to reduce the need for sedation in children requiring MRI or CT scanning.
• Trust performance against national audits was outstanding especially in the Sentinel Stroke National Audit Programme (SSNAP) and Myocardial Ischaemia National Audit (MINAP).
• Consultant paediatricians worked to provide access for patients. They set up outreach clinics in GP premises and held telephone clinics so that patients could stay in their own surroundings
• Staff who went the extra mile to drop off take-home medications or provide decaffeinated tea bags for a patient.
• The arrangement of a linked funeral service for the wife of the deceased who could not leave the hospital.
• The pharmacy service was excellent in providing take-home medications for patients.
• Additional support for critical care patients was provided by a follow-up nurse and a critical care outreach team, who also provided a cross-department education programme.
• In critical care, staff were encouraged and supported to undertake novel research projects, which they were able to present at national conferences as a knowledge-sharing strategy.
• Senior critical care staff had developed a robust five-year service plan in collaboration with unit staff, which was further evidence of the cohesive and supportive work culture we found.

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

Importantly, the trust must:

• Review and ensure robust processes are in place to provide compliance with mixed sex accommodation regulations especially within CDU, critical care (in relation to level one patients) and recovery when it is utilised for stepdown from critical care.
• Review its ‘Escalation Plan and Resuscitation Status’ (EPARS) forms to ensure, specifically, that the Mental Capacity Act and Deprivation of Liberty Safeguards aspects are appropriate.
• Review its Mental Capacity Assessment, Deprivation of Liberty Safeguards and EPARS policies to ensure they are compliant with law and reflect good practice.
• Ensure a robust process for data management with regard to medical photography and comply with all information governance protocols including informed consent, data protection, tracking and tracing and appropriate audit systems implemented to ensure quality improvement.

In addition the trust should:

• The trust should review the reporting of mortality and morbidity (M&M) discussions and learnings in surgery services to ensure consistent and effective documentation across the service.
• The trust should ensure staff compliance, across all staff groups, with mandatory and statutory training requirements.
• The trust should review referral to treatment times and aim to improve to ensure that surgical patients receive care within 18 weeks.
• The trust should ensure robust oversight of cancelled clinics and review theatre utilisation to support access to services and reduce patient treatment delays.
• The trust should ensure that the nutrition, hydration and toileting needs of patients are met when recovery is utilised as a step down area from CCU.
• The trust should ensure the principles of infection control are appropriate and monitored within the critical care unit for caring for potentially infectious patients.
• The trust should ensure appropriate senior staffing support to promote patient safety, including midwifery support in the management of complex cases on labour ward, appropriate supervision for high dependency patients and appropriate level of supervision within outpatients.
• The trust should consider quality measurements such as local targets for induction of labour, assisted deliveries and return of women with perineal problems.
• The trust should have action plans where it is not reaching national standards in maternity.
• The antenatal and postnatal ward F11 should review the practice of overnight stays for all partners on the ward.
• The trust should review the succession planning and development for staff in seconded or interim roles within the maternity service.
• The trust should consider developing strategic planning arrangements including action plans to achieve service goals, a performance dashboard for children’s services and a comprehensive transition policy to help all teenage patients adjust to adult health services.
• The trust should review the availability of staff with play specialist skills.
• The trust should review the options and nutritional value of food offered within the children’s service.
• The trust should review medical staffing, particularly within end of life care services to ensure consultant cover meets recommended national guideline levels.
• The trust should ensure that nurse staffing levels for children meet recommended national guideline levels.
• The trust should include sepsis monitoring on the maternity dashboard for inpatient areas.
• The trust should consider midwifery staffing and specialist midwives roles to support vulnerable groups.
• The trust should review the way patients in the last days or hours of life have their needs holistically assessed and how this is documented.
• The trust should review it’s specialist palliative care service for medical staffing and provision of a seven day service
• The trust should ensure that records management is secure and appropriate in all areas
• The trust should ensure a robust process for oversight and management of all policies and procedures.
• The service should ensure that risk scrutiny in governance meetings is robust and recorded so that there is assurance of management of risk.
• The trust should ensure dissemination of outcomes from audits and meetings is robust across all services.

Professor Sir Mike Richards

Chief Inspector of Hospitals