The County Hospital

Wye Valley NHS Trust was established in April 2011 and provides hospital care and community services to a population of 186,000 people in Herefordshire and a population of more than 40,000 people in mid-Powys, Wales. The trust also provides a full range of district general hospital services to its local population, with some links to larger hospitals in Gloucestershire, Worcestershire and Birmingham. During this inspection we only inspected the services provided by Hereford Hospital. We did not inspect community services provided by the trust. Therefore, the overall rating for community services remains as requires improvement, as per the September 2015 inspection.

There are approximately 236 beds of which 208 are general and acute, 22 maternity and six critical care beds within Hereford Hospital. The trust employs 2,601 whole time equivalent staff as of June 2016.

We carried out this inspection as part of our comprehensive programme of re-visiting trusts which are in special measures. We undertook an announced inspection from 5 to 8 July 2016 and unannounced inspections on 11, 17 and 18 July 2016.

Overall, we rated Hereford Hospital as requires improvement with four of the five questions we ask, safe, effective, responsive and well led being judged as requiring improvement.

We rated caring as good. Patients were treated with kindness, dignity and respect and were provided the appropriate emotional support.

Our key findings were as follows:

Safe

• There was a high vacancy rate which meant an increased use of agency and bank staff. The safer nurse staffing levels were planned in line with the national recommendations. The trust fill rate for registered nurses did not always meet the 95% target, ranging from 74.5% on Wye ward to 109.4% on Monnow ward for June 2016. The trust strategy was to cover unfilled registered nurse shifts with a health care assistant where appropriate, to help mitigate staffing level risk. For June 2016 the hospital health care assistant fill rate was 116% for day shifts and 122% for night shifts. We found actual staffing levels met planned staffing levels on most wards during our inspection. We found no incidents relating to staff shortages directly affecting patient care at ward level.
• Mandatory and statutory training compliance for June 2016 was at 86% which although had improved from 78% in July 2015, did not meet the trust target of 90%.
• Patients’ weight was not always recorded on patients’ prescription charts, which could potentially lead to the incorrect prescribing of the medicine.
• In maternity, the anaesthetic room used as a second theatre on the delivery suite was not fit for purpose. This could lead to increased risk of infection for mother and baby. 
• Staff were aware of their responsibilities regarding safeguarding procedures.
• Staff understood the importance of reporting incidents and had awareness of the duty of candour process.
• Staff understood their responsibility to report concerns and to record safety incidents and near misses. Staff received feedback on all incidents.
• Ward and clinical areas were visibly clean and staff were observed following infection control procedures.
• There were systems in place to assess, monitor and mitigate the risks relating to the health, safety and welfare of patients.

Effective

• The Summary Hospital-level Mortality Indicator (SHMI) and the Hospital Standardised Mortality Ratio (HSMR) indicated more patients were dying than would be expected. This had been reported to the trust board and an action plan was in place to understand and improve results.
• The caesarean section rate was significantly higher (worse) than the national average and the deteriorating rate was not recorded on the risk register.
• Most care was delivered in line with legislation, standards and evidence-based guidance. However, some trust guidelines needed updating.
• The service had a series of care bundles in place, based on the appropriate guidance for the assessment and treatment of a series of medical conditions.
• The trust had processes in place to monitor some patient outcomes and report findings through national and local audits and to the trust board. Performance in national audits had generally mixed results compared to the national average. Actions plans were in place to address areas needing improvement.
• Staff were clear about their roles and responsibilities regarding the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.

Caring

• Staff were observed being polite and respectful during all contacts with patients and relatives. Staff protected patients’ privacy and dignity.
• Patients felt involved in planning their care.

Responsive

• The emergency department consistently failed to meet standards in terms of the amount of time patients spent in the department and waited for treatment.
• Bed occupancy was consistently worse than the national average.
• Patients were unable to access the majority of outpatient services in a timely way for initial assessments, diagnoses and/or treatment. The trust had put a system in place to assess, monitor and mitigate the risks relating to the health, safety and welfare of patients on the waiting list.
• The trust did not consistently meet all cancer targets for referral to treatment times.
• Overall referral to treatment indicators within 18 weeks for admitted surgery patients was worse than the England average.
• The percentage of patients that had cancelled operations was worse than the England average.
• Delays in accessing beds in hospital were resulting in mixed sex occupancy breaches on the intensive care unit each month.
• The trust did not have an electronic system in place to identify patients living with dementia or those that had a learning disability.
• Staff adapted care and treatment to meet patient’s individual needs.
• We saw examples of services planning and delivering care to meet the needs of patients.
• Systems and processes were in place to provide advice to patients and relatives on how to make a complaint.

Well-led

• The trust had governance oversight of incident reporting and management. Some local risks had not always been identified on risk registers.
• Local leaders demonstrated good understanding of the risks, issues and priorities in human resource management. However, overcoming some of these issues, such as recruitment, remained a significant challenge.
• The trust had a vision, their mission and their values. However, these were not fully embedded or understood by staff.
• Following the trust being placed into special measures in October 2014, a comprehensive quality improvement plan was developed, which included a number of projects and actions at local level. We saw that the action plans were reviewed regularly, with monitoring of compliance against targets and details of completed actions.
• There was a sense of pride amongst staff towards working in the hospital and they felt respected and valued.
• The trust implemented a new structure in June 2016, with three service units reduced to two divisions, medical and surgical. Although staff felt the reconfiguration was positive and provided more support we were unable to assess the sustainability and effectiveness of the restructure as this had not yet been embedded into the trust.

We saw several areas of outstanding practice including:

• Services for children and young people were supported by two play workers (one was on maternity leave at the time of inspection). The play workers regularly made arrangements for long term patients to have days out to different places, including soft play areas or bowling. An activity was arranged most months and the play workers sourced the activities from local businesses who donated their good and/ or services. This meant that patients with long term conditions could meet peers who also regularly visited the hospital. Patients found this valuable and liked the opportunity to meet patients who had shared experiences.
• There was a children’s and young people’s ambassador group which was made up of patients who used or had used the service. We spoke with some members of the ambassador group who told us that they were involved in the service redesign when developments took place and improving the service for other patients.
• The respiratory consultant lead for NIV had developed a pathway bundle, which was used for all patients requiring ventilator support. The pathway development was based on a five-year audit of all patients using the service and the identification that increased hospital admissions increased patient mortality. The information gathered directed the service to provide an increased level of care within the patient’s own home. Patients were provided with pre-set ventilators and were monitored remotely. Information was downloaded daily and information and advice feedback to patients by the medical team. This allowed treatments to be altered according to clinical needs. The development had achieved first prize in the trust quality improvement project 2016.
• The newly introduced clinic for patients with epilepsy had enlisted the support of a patient with epilepsy; their views had helped the clinic develop so that the needs of patients were met.
• Gilwern assessment unit was not identified as a dementia ward, however, this had been taken into consideration when planning the environment. The unit had been decorated with photographs of “old Hereford” which were used to help with patients reminiscing. Additional facilities included flooring that was sprung to reduced sound and risk of harm if patients fell, colour coded bays and wide corridors to allow assisted mobility. Memory boxes were available for relatives to place personal items and memory aids for patients with a history of dementia, and fiddle mittens provided as patient activities. The unit provided regular activities for patients, which included monthly tea parties and games.

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

Importantly, the trust must:

• The trust must ensure that all staff receive safeguarding children training in line with national guidance, in particular in the emergency department.
• The trust must ensure that enough staff are trained to perform middle cerebral arterial Doppler assessments, to ensure patient receive timely safe care and treatment.
• The trust must ensure there are enough sharps bins available for safe and prompt disposal of used sharps.
• The trust must ensure that patients’ weight is always recorded on patients’ prescription charts, to ensure the correct prescribing of the medicine.
• The trust must ensure that medicine records clearly state the route a patient has received medicine, in particular, whether a patient has been given the paracetamol orally or intravenously.
• The trust must ensure all medicines are stored in accordance with trust polices and national guidance, particularly in outpatients.
• The trust must ensure that all patients receive effective management of pain and there are enough medicines on wards to do this.
• The trust must ensure all staff have received their required mandatory training to ensure they are competent to fulfil their role.
• The trust must ensure all staff are supported effectively via appropriate clinical and operational staff supervisions systems.
• The trust must ensure staff receive appraisals which meet the trust target.
• The trust must ensure that patients are able to access surgery, gynaecology and outpatient services in a timely way for initial assessments, diagnoses and/or treatment, with the aim of meeting trust and national targets.
• The trust must continue to take action to address patient waiting times, and assess and monitor the risk to patients on the waiting list.
• The trust must ensure the time taken to assess and triage patients within the emergency department are always recorded accurately.
• The trust must ensure effective and timely governance oversight of incident reporting and management, particularly in children and young people’s services.
• The trust must ensure all policies and procedures are up to date, and evidence based, including the major incident policy.

The trust must ensure that all risks are identified on the risk register and appropriate mitigating actions taken.

In addition the trust should:

• The trust should ensure all vacancies are recruited to.
• The trust should continue to complete mortality reviews with the aim of reducing the overall Summary Hospital-level Mortality Indicator for the service.
• The trust should ensure patient records are stored appropriately to protect confidential data.
• The trust should ensure all patient records are fully completed, including stroke pathway documentation and communication detailing interactions and treatments provided within the care plan evaluation sheets.
• The trust should ensure patients receive care and treatment in a timely way to enable the trust to consistently meet key national performance standards for emergency departments.
• The trust should ensure delays in ambulance handover times are reduced to meet the national targets.
• The trust should ensure initial patient treatment times are reduced to meet the national target for 95% of patients attending the emergency department to be admitted, discharged or transferred within four hours.
• Ensure that each service has a local vision and strategy which is disseminated and understood by all staff so that it is embedded within the service.
• The trust should ensure that systems and processes are in place to ensure cleanliness of equipment within the emergency department.
• The trust should ensure that systems are in place to provide adequate nutrition and hydration to patients in the emergency department and clinical assessment unit.
• The trust should ensure treatment bays in the emergency department resuscitation area protect patients’ privacy and dignity.
• The trust should review staff safety and provision of an alarm call system in the rapid assessment area.
• The trust should review its arrangements for transporting patients home if they need to travel on a stretcher, with emphasis on improving patient flow.
• The trust should ensure that electronic discharge letters are completed in a timely manner to prevent delays in the preparation of patient’s medication to take home and delays in patient discharge.
• The trust should ensure where possible, patients are placed in the most appropriate clinical area.
• The trust should consider implementing a checklist for transferring patients between wards, to ensure transfer is appropriate and maintains patient safety.
• The trust should consider implementing a risk assessment for the admission of medical patients to outlying wards, to ensure admission is appropriate and maintains patient safety.
• The trust should ensure unnecessary patient moves are minimised at night.
• The trust should continue to work with local stakeholders to improve the discharge pathway and facilitate timely patient discharge.
• The trust should ensure mixed sex breaches are prevented.
• The trust should consider employing a lead nurse for learning disabilities to support patients.
• The trust should ensure that all staff are aware of the trust structure and who their managers are.
• The trust should ensure that patents privacy and dignity is protected at all times, in particular during handover on Leadon ward.
• The trust should ensure that there are action plans as a result of audits, to promote improvements.
• The trust should ensure that cancelled operations are prevented; and if cancelling an operation is essential, patients are then treated within 28 days as per NHS England standard.
• The trust should ensure staff are aware of the trust mission, vision, and strategic objectives.
• The trust should consider a follow-up clinic for patients discharged home after an intensive care unit admission, as recommended in National Institute for Health and Care Excellence guidance.
• The trust should ensure that flow is maintained throughout the hospital to ensure there is capacity to admit patients that required critical care services and discharge patient in a timely manner.
• The trust should ensure there are systems and processes in place to keep patients safe, particularly in maternity services where, the anaesthetic room used as a second theatre on the delivery suite was not fit for purpose.
• The trust should ensure there is clear oversight of outcomes and activity in maternity services.
• The trust should ensure measures are in place to reduce the caesarean section rate.
• The trust should ensure that meeting minutes clearly record recommendations and lessons learnt from incidents.
• The trust should ensure that appropriate transition arrangements for children are clearly defined.
• The trust should ensure there is an acuity tool to be used to determine patient dependency levels and staffing requirements in paediatrics.
• The trust should ensure that there is oversight of the service arrangements for the mortuary team to ensure that staff training and supervision is in place.
• The trust should ensure that effective information on the percentage of patients who were discharged to their preferred place within 24 hours is collected.
• The trust should ensure that corridors where patients wait for their consultation and treatment in the Victoria Eye Unit do not pose a risk to patients with visual difficulties.
• The trust should ensure there is signage on the doors to indicate if a compressed gas is stored in the room, in line with the Department of Health guidance (Medical gases. Health Technical Memorandum 02-01: Medical gas pipeline systems. Part B: Operational management, 2006).
• The trust should ensure that complaints are responded to within the trust target of 25 days.
• The trust should minimise the percentage of outpatient clinics cancelled.
• The trust should ensure all equipment has safety and service checks in accordance with policy and manufacturer’ instructions and that the identified frequency is adhered to, particularly in outpatients, the emergency department and the intensive care unit.

The trust was placed into special measures in October 2014. Due to the improvements seen at this inspection, I have recommended to NHS Improvement that the special measures are lifted.

Professor Sir Mike Richards

Chief Inspector of Hospitals