William Harvey Hospital

Updated 20 December 2023

Medical care (including older people's care)

Our rating of this location stayed the same. We rated it as requires improvement because:

• The service did not ensure staff at all levels completed the necessary mandatory and statutory training to enable them to carry out the duties they are employed to perform.
• The service did not always have enough staff to care for patients. Staff did not always make sure equipment, such as resuscitation trolleys, were accurately checked and safe to use.
• The service did not ensure systems and processes to mitigate risk including fire safety, infection prevention and control and patients’ privacy and dignity; relating to the environment, premises, and equipment, were safe.
• The service did not ensure systems and processes to monitor cleanliness of the environment and equipment were sufficient to reduce infection prevention and control risk and staff did not always follow the infection prevention and control policy. Managers monitored the effectiveness of the service but did not always ensure staff were competent.
• Staff did not always complete patient risk assessments on admission to medical wards. Managers did not always feed back incident outcomes to staff and staff did not always report near misses or potential harms.
• The service did not always ensure they communicated effectively with patients when making decisions about patient care.
• The service did not always ensure chemicals that are hazardous to health were stored safely and securely. The service did not always keep patient records secure.
• Not all leaders ran services well and information systems were not reliable and did not always support staff to develop their skills.

However:

• Staff understood how to protect patients from abuse. Staff acted on risks to patients and kept good care records.
• Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Most key services were available seven days a week.
• Staff mostly treated patients with compassion and kindness, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families, and carers.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it.
• Staff were involved in developing the service’s vision and values. Most staff felt respected, supported, and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to continually improving services.

Services for children and young people

Our rating of this location went down. We rated it as requires improvement because:

• Staff had varied compliance with training in key skills. Medicines were not always managed well. Safeguarding training was below the trust targets for medical staff. Agency staff did not consistently have an induction.
• Managers did not ensure staff were competent in key skills and did not fully monitor the effectiveness of the service. Staff did not always receive appraisals and clinical supervision was not available for nursing staff. Key services were not available and there was no plan to address this at the time of inspection.
• The service did not always consider the individual needs of children and young people receiving treatment and care.
• Leaders ran services well using reliable information systems but did not support staff to develop their skills. Leaders did not always recognise and escalate concerns within the department.

However:

• The service had enough staff to care for children and young people and keep them safe. The service understood how to protect children and young people from avoidable harm, and managed safety well. The service managed infection risks well. Staff assessed risks to children and young people, acted on them and kept good care records. The service managed safety incidents well and learned lessons from them.
• Staff gave children and young people enough to eat and drink and gave them pain relief when they needed it. Staff worked well together for the benefit of children and young people and supported them to make decisions about their care. They had access to information to help them provide treatment and care safely.
• Staff treated children and young people with compassion and kindness. They respected their privacy and dignity and helped them understand their conditions. Staff provided emotional support to children and young people, families and carers.
• The service made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
• Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of children and young people receiving care. Staff were clear about their roles and accountabilities. The service engaged well with children, young people and the community to plan and manage services.

Urgent and emergency services

Our rating of this location stayed the same. We rated it as requires improvement because:

• Safeguarding training was below trust targets for medical staff. Managers did not ensure staff were competent in key skills and did not fully monitor the effectiveness of the service. Staff did not always receive appraisals and there was limited clinical supervision was in place for nursing staff.
• The service did not have enough staff to care for patients and keep them safe. Staff assessed risks to patients, acted on them however they did not always re-assess patients or maintain good care records. Staff did not always report incidents or near misses in line with trust policy.
• Overcrowded departments meant patients privacy and dignity could not always be respected.
• Leaders of the service described a disconnect between the emergency department and services within the hospital. They described a lack of trust-wide ownership of the challenges faced by the emergency department.
• The lack of patient flow into and out of the emergency department, and into the hospital, had a significant impact on both staff and patients.

However:

• Doctors, nurses and other healthcare professionals within the emergency department worked together as a team to benefit patients.
• The service planned care to meet the needs of local people, took account of individual needs, and made it easy for people to give feedback.
• Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service promoted equality and diversity in daily work.

Updated 20 December 2023

Updated 20 December 2023

Updated 18 November 2015

We found the service delivered at the William Harvey Critical Care unit (CCU) to be safe, effective, caring, responsive and well led.

However, we continue to recognise a concern with delayed discharges from the unit which may suggest problems with patient flow elsewhere in the hospital. Capacity in the unit was also a concern, given the 100% occupancy rates despite the additional two unfunded beds in operation. The location of these beds was not desirable but staff had taken reasonable steps to minimise the risk to patients and staff. We also noted a robust strategy and vision in the unit, but were uncertain about whether it reflected the trust vision. We acknowledge a recent change to the trust leadership, and the on-going financial challenges, which presented an obstacle to achieving the plan. We recognised the frustrations of staff in terms of the stagnant situation in which they find themselves due to the environmental and financial restraints. The CCU did not always manage to achieve the national recommendation of ensuring a supernumerary shift leader for all shifts. However, we acknowledge that there has been a significant improvement in supernumerary management cover since our last inspection. A standardised approach to inotropic infusion concentrations (modifies the force of muscle contractions) and meeting national guidance for the x-ray checking of Nasogastric (NG) tubes had been implemented across all three sites.

We found effective systems in place to ensure safe care. The care delivery was continuously monitored and assessed to ensure a high quality care for the patients using the service. There was a positive culture towards reporting and learning from adverse events, and a refreshingly positive emphasis put on avoiding recurrence.

The care delivered reflected best practice and national guidance. Needs were risk assessed and the unit could demonstrate a track record of delivering harm free care. There were appropriate measures in place to ensure that patients were protected from the risk of acquiring hospital acquired infections, and staff were observed to follow trust infection control guidance.

Patients and their loved ones had their dignity and human rights respected and protected. The unit provided an ample and varied supply of information for relatives, and actively encouraged their feedback and comments. If a complaint was raised the service learned from the feedback given, and ensured that people felt listened to.

The relatives we talked with during the inspection were very complimentary about the service their loved ones had received, and the caring and approachable attitude of the staff. Relatives were also involved in the planning of care and told us that they had access to sufficient information about their loved ones’ condition. Patients had their right to consent to care respected and, where possible, formal consent was obtained. Staff were found to make reasonable adjustments to reflect the needs of their patients. The service provided a person centred bereavement service for families.

There were suitable arrangements in place for dealing with foreseeable emergencies. Patients had their health needs risk assessed and balanced with safety, and had their rights and preferences taken into consideration. We noted effective systems to ensure patients’ nutritional and pain needs were addressed and managed. Medication management reflected national and trust guidance.

The CCU had appropriate numbers of staff with the required skills to meet people's individual care needs. Staff were subject to competency-based learning and assessments, and were provided with support to learn, develop and progress professionally.

A multidisciplinary approach to care was noted, as was the provision of a seven day service. There was a consultant-led ward round twice daily which meant that patients conditions and progress were continuously monitored. There were effective systems in place to ensure that deteriorating patients had their care needs reviewed in a timely manner. This was also true of patients who were in ward areas as they had their conditions reviewed by the outreach team using an electronic monitoring system.

There was strong leadership in the CCU and staff expressed feeling valued and listened to. They voiced satisfaction with the local unit management and the support provided to them. Numerous steps had been put in place to address the culture concerns raised in the last inspection. Staff told us these measures had a positive impact on morale and on their working environment.

Updated 5 September 2018

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

• Information was not always available for staff to deliver safe care and treatment to patients at the end of life. Care records for patients on the ‘care of the dying patient and their family plan’ were seen to be inconsistently completed or not used appropriately for patients at the end of life.
• Anticipatory prescribing for medicines ‘just in case’ patients at the end of life experienced common symptoms was not always in line with trust guidance.
• Lessons were not always learned and improvements made when things went wrong. There were no examples of reported or recorded incidents relating to the care of patients at the end of life, however there was evidence of incidents relating to the mortuary and anticipatory prescribing.
• Records of mental capacity assessments relating to decisions regarding ‘Do not attempt cardiopulmonary resuscitation’ (DNACPR) were not maintained.
• Staff did not always have the skills, knowledge and experience to deliver effective care, support and treatment. A range of end of life care training was available but not all link nurses on the wards had completed the mandatory training for the role.
• The palliative care service was not available face to face seven days a week.
• Patients were not always identified who were in need of extra support. For example, there was no framework in place for identifying patients in the last year of life or those with an uncertain recovery who were at risk of dying. There was no framework for advance care planning.
• Capacity issues within the mortuary led to processes for storing the deceased that did not ensure that people’s dignity was respected during care after death. We were told that the practice of storing two bodies in the space meant for one had occurred during busy periods, particularly during the winter months.
• The trust did not record the percentage of patients who were discharged to their preferred place of care at the end of life. Discussions about preferred place of care were not consistently held in advance of the last days of life.
• There was no organisation specific end of life care strategy or aligned action plans.
• Processes for managing risks, issues and performance were not always effective. Risks were not always identified and recorded on the risk register or adequately mitigated.
• Governance structures were in place; however their effectiveness was impacted by a lack of structured action planning and prioritising.
• There were quality assurance processes evident, for example, in relation to audit and surveys. However, improvement plans were not detailed, structured or timely.

However:

• Syringe drivers were accessible and the administration of medicines via the pump was appropriately monitored.
• Anticipatory medicines ‘just in case’ patients at the end of life experienced symptoms were available.
• People’s needs were assessed and care and treatment delivered in line with evidence based guidance to achieve effective outcomes.
• People’s nutrition and hydration and pain management needs were identified and met in relation to national guidance for caring for people in the last days and hours of life.
• People’s care and treatment outcomes were monitored through trust participation in the national end of life care audit there was evidence of improvement over time and trust participation in relevant quality improvement initiatives.
• The learning needs of staff had been identified and there was a range of training initiatives aimed at engaging generalist staff in improving patient care for those at the end of life.
• The service ensured that people are treated with kindness, respect, and compassion, and that they are given emotional support when needed. Staff were committed to ensuring the patient experience at the end of life was as positive as possible.
• People could access care in a timely way. Ninety eight percent of patients were seen within 72 hours of referral.
• Spiritual support services were available to patients of different religions and beliefs, including for those patients with no particular faith.
• Leaders were visible and approachable. The end of life care board was made up of a range of senior staff including executive directors, matrons, consultants, hospice staff and members of the specialist palliative care team.
• An end of life care working group had been established at William Harvey Hospital to improve end of life care, although comprehensive action plans were not in place.
• There were governance structures and culture to support end of life care, with clear leadership at executive and senior staffing levels and an end of life care board responsible for decision making.
• People’s views were gathered through a bereavement survey across the trust. This provided feedback to staff on the experience of relatives.
• There was some evidence of innovation, in particular with the development of a nationally recognised compassion symbol in collaboration with the local hospice.

Updated 26 May 2023

Updated 18 November 2015

The Outpatient department was well led and had improved since implementing an outpatient improvement strategy. Despite the strategy being relatively new, through structured audit and review the department was able to evidence improvements in health records management, call centre management, referral to treatment (RTT) processes, increased opening hours, clinic capacity and improved patient experience.

Although there was still improvement required in referral to treatment pathways the outpatients department and trust demonstrated a commitment to continuing to improve the service long term.

As a part of the strategy the trust had pulled its outpatient services from fifteen locations to six. We inspected five of these locations during our visit.

Managers and staff working in the department understood the strategy and there was a real sense that staff were proud of the improvements that had been made. Progress with the strategy was monitored during weekly strategy meetings with the senior team and fed down to department staff through staff meetings and bulletins.

Evidence based assessment, care and treatment was delivered in line with National Institute for Health and Care Excellence (NICE) guidelines by appropriately trained and qualified staff.

A multi-disciplinary team approach was evident across all the services provided from the outpatients and diagnostic imaging department. We observed a shared responsibility for care and treatment delivery. Staff were trained and assessed as competent before using new equipment or performing aspects of their roles.

We saw caring and compassionate care delivered by all staff working at outpatients and diagnostic imaging department. We observed throughout the outpatients department that staff treated patients, relatives and visitors in a respectful manner.

Nurse management and nursing care was particularly good. Nurses were well informed, competent and went the extra mile to improve patient’s journey through their department. Nurses and receptionists followed a ‘Meet and Greet’ protocol to ensure that patients received a consistently high level of communication and service from staff in the department.

Updated 5 September 2018

Our rating of this service improved. We rated it as good because:

• The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. There was an open and transparent culture of incident reporting and investigation. Incidents were recorded on electronic systems that incorporated fail-safes about aspects such as duty of candour. Managers investigated incidents and shared lessons learned with staff to continuously improve patient safety.
• All the areas we inspected were visibly clean and tidy. The service controlled infection risks very well. Staff kept themselves, equipment and the premises clean and used effective control measures to prevent the spread of infection.
• The service maintained suitable premises and sufficient equipment to support safe care and treatment.
• The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. Nursing staff turnover and vacancy rates were close to trust averages and where bank or agency staff were used, the trust had sufficient controls in pace to manage risk. Medical staff turnover and vacancy rates were below trust averages.
• Records were clear, up-to-date and available to all staff providing care. The service used safety monitoring results well. Staff collected safety thermometer information, such as rates of falls, pressure ulcers and catheter-acquired urinary tract infections and shared it with staff, patients and visitors.
• The service provided care and treatment based on national guidance and best practice. The service carried out audits to check staff followed internal policies and guidance.
• Patients had good outcomes following surgery. Results from national audits showed the service performed well, with patient outcomes close to the same as other NHS acute hospitals nationally.
• The service made sure staff were competent for their roles. Managers appraised staff performance, and we saw evidence of meaningful appraisals. Competency records we reviewed provided assurances staff had the skills they needed to do their jobs.
• Staff of different kinds worked very well together as a team to benefit patients. We saw positive examples of multidisciplinary working between different staff groups.
• Staff obtained patient consent and understood their roles and responsibilities under the Mental Capacity Act 2005. They knew how to support patients who lacked the capacity to make decisions about their care.
• Staff cared for patients with compassion, kindness and respect. Feedback from patients confirmed that staff treated them well and were involved with their families in decisions about their care and treatment.
• Managers promoted a positive culture that supported and valued staff. Staff spoke positively about the culture and described good working relationships with colleagues and managers.
• The service acted to actively engage with staff and seek their views through focus groups and other forums.

However:

• Referral to treatment times (RTT) for admitted pathways for surgery were worse than the England average. In December 2017, 57% of patients were treated within 18 weeks, which was worse than the England average of 72%.
• While we saw improvement in mandatory training rates in nursing and other staff groups, compliance rates for medical staff was 67% on average and medical staff did not meet the trust target of 85% of training for any mandatory training course. This meant that medical staff might not have the most up to date information about these critical areas.
• We saw a similar trend in safeguarding training. Nursing staff compliance rates exceeded the trust target while medical staff training rates were 28%, appreciably below the 85% trust training target.

Updated 24 June 2021