11 February to 12 March 2020
During a routine inspection
We did not change ratings at trust level at this inspection. Please see summary of services at Great Western Hospital.
This is an organisation that runs the health and social care services we inspect
We did not change ratings at trust level at this inspection. Please see summary of services at Great Western Hospital.
Our rating of the trust stayed the same. We rated it as requires improvement because:
Acute services at Great Western Hospital were rated requires improvement overall. The safe and responsive key questions were rated as requires improvement.
However, we rated the effective, caring and well led key questions as good. Trust-wide leadership was also rated good. Community services were rated good overall, with all key questions rated good. The overall rating for services for children and young people and outpatients improved since our last inspection; both services were rated good.
Our findings for each of the core services inspected this time is summarised below:
Urgent and emergency care
Our overall rating of this core service remained as requires improvement. There was no change to the rating for the safe and responsive domains, which remained as requires improvement. This was because the emergency department continued to be frequently crowded and patients did not always receive prompt care and treatment in the right setting. The rating for effective stayed as good because the emergency department used national audits to drive improvements in the quality and effectiveness of care and treatment. Teams and services worked well together to ensure patients received coordinated care. The rating for caring, previously rated outstanding, went down to good. Feedback from patients and relatives remained consistently good and we observed compassionate and understanding care; however, we found no examples of outstanding care. The rating for well led stayed the same and was rated as good. The department had improved in several key areas, governance and quality improvement were prioritised and leaders had the knowledge and skills to run the department and they were respected by staff.
Medical care
Our overall rating for medical care remained as requires improvement. Safe remained as requires improvement. Some areas were not clean and hygienic. Staff did not always observe necessary precautions to prevent and control infection. There was a continuing shortage of nursing staff and heavy reliance on bank and agency staff. Staff were not up to date with their mandatory training. Effective remained as requires improvement. Patient outcomes, when benchmarked did not always compare favourably with the England average. Performance against national standards in stroke care remained consistently poor. Caring remained as good. Patients received a caring service from kind and empathetic staff. Responsive remained as requires improvement. Patients did not always receive care in the right setting due to a shortage of inpatient beds. Some patients were accommodated in wards and departments in a specialty other than that for which they were intended, and sometimes in departments which were not designed for inpatient care, or where single sex accommodation could not be provided. The rating for well led went down and we rated it as requires improvement. The service had failed to make significant improvement in several key areas since our last inspection.
Surgery
Our overall rating for surgery remained as requires improvement. Safe remained as requires improvement. Although we saw some improvements, for example in mandatory training compliance, there were a number of regulatory breaches. We had concerns about infection control practices, record keeping standards and a lack of documented patient risk assessments. Effective remained rated as good. There was coordinated multidisciplinary care and staff used evidence-based care pathways for patients admitted for surgery. Caring remained as good. Feedback we received from patients and relatives was consistently positive. Staff showed an encouraging, sensitive and supportive attitude to patients and their relatives. Responsive remained as requires improvement. There were insufficient surgical beds to meet demand and some patients were cared for in unsuitable settings. Our rating for well led improved. It was rated good because leaders had the knowledge, skills and integrity to lead the service effectively and they were well respected by staff. There were effective governance processes to ensure quality and safety were monitored and risks were managed.
Children and young people
Our overall rating of this service went up to good. We inspected only the safe and well led domains, both of which had improved, with a rating of good. Safe was rated good because, although there was still a shortage of registered children’s nurses, there was improved oversight of nurse staffing levels, using an acuity tool, and gaps in rotas were mostly filled by temporary staff. There was some improvement in mandatory training compliance for medical staff, although this still required further improvement. Well led was rated good because new managers were well respected by staff; there was a noticeable change in culture, and staff felt supported, able to contribute ideas and voice concerns if they needed.
Outpatients
We previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings. We rated this service as good overall. We rated safe as good because staff complied with safety systems to protect people from avoidable harm. We inspected the effective domain but did not rate it due to a lack of national data available to the CQC. We rated caring as good because patients were treated with kindness, compassion dignity and respect. We rated responsive as good because the service was performing better than the national standards for patients waiting times. We rated well led as good because there was a clear improvement strategy for outpatient’s services; staff were engaged and there was a positive culture where staff felt supported and valued.
Community health services for adults
We had not previously inspected this service. We rated this service good overall, with all domains rated good. Safe was rated good because staff complied with safe systems in all areas. They reported incidents and monitored patients in order to maintain and improve safety. We rated effective as good because patients received evidence-based care, delivered by well-coordinated multidisciplinary teams of competent staff. We rated caring as good because staff took the time to interact with patients and those close to them in a respectful, compassionate and considerate way. Patients and their relatives/carers were actively involved in their treatment and care. We rated responsive as good because services reflected people’s needs and ensured flexibility, choice and continuity of care. We rated well led as good because leaders were appropriately skilled and committed to service improvement. Staff felt valued and supported. There were effective governance systems to support safety and quality.
Community inpatients
We had not previously inspected this service. We rated this service good overall, with all domains rated good. Safe was rated good because staff followed safety processes to protect patients from avoidable harm. Staffing levels were monitored to ensure safe levels were maintained. We rated effective as good because staff used evidence-based practice to provide care and treatment. There was good team working between acute and community colleagues. We rated caring as good because staff promoted patient choice and acted as advocates for patients in their care. Relatives spoke highly of the emotional support provided to them and their loved ones to help them come to terms with their situation. We rated responsive as good because patients were supported to receive individualised care closer to their homes. We rated well led as good because there were effective governance processes which aligned with trust processes and risks were managed well. Staff felt supported and valued by managers.
We rated safe, effective, caring, responsive and well-led as good, because:
However:
We rated this service as good overall, with all key questions rated good. The service had not been inspected before under our current methodology, so we were unable to provide a comparison of ratings. We rated it as good because:
However:
We carried out an announced inspection between 21 and 23 March 2017 and an unannounced inspection at Great Western Hospital on 26, 27 and 28 March 2017 and 3 April 2017. This was a focused inspection to follow up on concerns from a previous inspection. As such, not all domains were inspected in all core services.
The inspection team inspected the following six core services at Great Western Hospital:
We also inspected:
We did not inspect end of life care or maternity and gynaecology services (previously rated good). We did not inspect the effective, caring or responsive domains for services for children and young people (previously rated good). The effective domain was inspected but not rated for outpatients and diagnostic imaging.
Overall we rated Great Western Hospitals NHS Foundation Trust as requires improvement.
We have deviated from the aggregation principles by not aggregating the ratings for (community) urgent care services to the overall trust rating. This is in recognition of the fact that, at the time of our inspection, the trust had only been running these services for six months. We also deviated from the aggregation principles for the well led rating at provider level. Please see the well led section below.
Safe
We rated the safe domain as requires improvement overall. Urgent and emergency services, medical care, surgery, critical care, services for children and young people, the urgent care centre and outpatients and diagnostic imaging were all rated as requires improvement.
However:
Effective
We rated the effective domain as good overall. It was rated as good for urgent and emergency care, surgery, critical care. It was rated as requires improvement for medical care and the urgent care services. It was inspected but not rated for outpatients and diagnostic imaging.
However:
Caring
We rated the caring domain as good in medical care, surgery, critical care, outpatients and diagnostic imaging, and the urgent care centre. In urgent and emergency care we rated caring as outstanding.
However:
Responsive
We rated the responsive domain as requires improvement overall. It was rated as requires improvement for urgent and emergency care, medical care, surgery and outpatients and diagnostic imaging. It was rated as good for critical care and the urgent care centre.
However:
Well Led
We rated the well led domain as good overall. It was rated as good for urgent and emergency care, medical care, critical care, outpatients and diagnostic imaging and the urgent care centre. It was rated as requires improvement for services for surgery and children and young people. We have deviated from our ratings aggregation principles in recognition of the significant improvements made since our last inspection. There was good board oversight of quality, safety and the trust's financial situation, which had improved. Significant challenges in respect of capacity, access and flow were well understood. The trust was working with partners to address these challenges to ensure future sustainability of healthcare in Swindon.
However:
We saw several areas of outstanding practice including:
However, there were also areas of poor practice where the trust needs to make improvements.
Importantly, the trust must:
In addition the trust should:
Professor Sir Mike Richards
Chief Inspector of Hospitals
We rated the urgent care centre to be requires improvement overall. This was because:
However:
Great Western Hospitals NHS Foundation Trust consists of one acute hospital (Great Western Hospital) and four community hospitals, of which three provide inpatient services. There are a total of 450 acute beds (including 12 critical care beds and 38 maternity beds) at the Great Western Hospital. Chippenham hospital as 37 beds spread over two wards, one ward of 25 beds at Warminster hospital and one ward of 26 beds at Savernake hospital. The trust provides acute and community healthcare services to a population of around 480,000 people from Wiltshire and the surrounding areas.
Overall, Great Western Hospitals NHS Foundation Trust was rated as requiring improvement. We rated it as good for caring and as requiring improvements in safety, effectiveness, being responsive to patients’ needs and being well-led. Maternity and Gynaecology services and End of Life care were rated as good overall with all other core services rated as requiring improvement. We rated safety within the Urgent and Emergency care services as inadequate. Within the community services, we rated services to children and young people as outstanding. All other community service was judged as good.
Our key findings were as follows:
We saw several areas of outstanding practice including:
However, there were also areas of poor practice where the trust needs to make improvements.
Importantly, the trust must:
Professor Sir Mike Richards
Chief Inspector of Hospitals
Overall rating for this core service GOOD
Overall we rated all these adult community services as good. The trust provides a range of community services including district nursing, physiotherapy, continence, podiatry, wheelchair services, learning disability services, dietetics, diabetes, respiratory,adult speech and language therapy, neurology and tissue viability. During the inspection we looked at community services for adults, community outpatients and diagnostic services.
We rated all the five domains of this core service as good and found that some aspects of the effective and well led domains were outstanding.
The community services had a commitment to providing harm free and safe care. There were procedures in place to improve pressure care treatment through staff training and also the use of new innovative treatment techniques.
We found there were robust procedures in place for reporting incidents and staff we spoke with were aware of the processes to follow. We saw the learning from incidents was cascaded and improvements were initiated.
Equipment was well maintained and clinics and patient waiting areas were kept clean hygienic and safe.
Staff were completing mandatory training. The integrated health team was 80% compliant with mandatory training. which met the trust target of of 80%. Infection prevention and control mandatory training was completed by 85% of the team.
There were relevant and current evidence based guidance and best practice in use by clinicians across all the various services. We considered some of this to be outstanding practice. We found some outstanding practice where clinicians accessed information and knowledge through colleagues, clinical networks and professional associations.
Staff we spoke with said they considered that the trust valued training and they, “felt invested in”. Staff told us the training was generally of a high standard, was well planned, organised and professionally delivered.
Staff received annual appraisals and there were excellent levels of support from colleagues and managers. All staff we spoke with said they were well supported and supervised by their line manager. However there were inconsistencies around the arrangements for clinical supervision.
There were numerous examples of positive, professional multi-disciplinary working. We considered some of these to be examples of outstanding practice. This occurred within the integrated teams, between the county wide specialist teams, with GP surgeries and with hospital based clinicians. Staff were able to demonstrate knowledge of the various other professionals they worked with, how they shared information and also sought advice and support from different specialists.
Patients were treated with kindness, dignity respect and compassion by the clinical staff and also by reception and other staff working when they visited the community hospitals.
Various developments and changes in the planning and delivering of community services had taken place over the previous 18 months. There was a drive to implement integrated Integrated Teams to work closely around primary care to make care accessible to patients as locally as possible. The Integrated Teams provided a seven day service between 7am and 10 pm. The out of hours service between 10pm and 7am was commissioned to a private provider.
We saw and heard about various initiatives in place to improve the service to patients, including pressure care treatment, multi-disciplinary working with acute colleagues and early intervention treatment for stroke patients.
Patients living in the community were able to access care and treatment in a timely way, though there were some breaches of the 18 week national referral to treatment target in certain services. Action plans were in place to address the shortfalls in breaching these targets
Staff were well informed about the strategy for community services. They were able to explain the values and objectives, such as working closely with primary care services, providing a holistic service, promoting healthy lives and working in an integrated team of professionals.
There was a governance framework in place which gave clear guidelines over lines of responsibility. There were clear processes in place to monitor quality and risk and deliver an improving service. We found that there were some outstanding examples of auditing and action planning against identified shortfalls or areas for improvement by the different Integrated Teams and specialist county wide services.
The leadership and culture reflected the vision and values of the trust and encouraged staff engagement with delivering quality community based services. We found examples of outstanding leadership being provided by heads of locality and the clinical leads for the specialist services.
There was a culture of teamwork that permeated through the community adults service.
There were examples of services taking action to promote improvement and best practice and to improve the service delivered to the community. We saw examples of outstanding and innovative ideas being put into action.
During the inspection we spoke with approximately 70 staff, including managers, clinicians, administrators, technical staff and domestic staff. We also spoke with the trust director for community services.
We spoke with 39 patients and relatives. We visited locations across the geographical area where services were run and also where they were managed and coordinated. We observed care and support being provided by clinicians both in clinics and in the patients own homes. We ran drop in session in the three community hospitals where staff could talk to inspectors.
We looked at a sample of patients records and also trust documentation, including training records, policies, monitoring data and risk registers.
We took feedback from the public via our website and through public listening events. We also received feedback through the healthwatch organisation who had sought the views of patients.
Overall rating for this core service Outstanding
We found that services were safe, effective, caring, responsive and well led. The staff were competent, compassionate, enthusiastic and well supervised in their role. During the inspection, we met with managers, staff, children, young people and parents in a variety of community settings. We observed staff delivering care being in schools, outpatient clinics and in the child’s own home. There was an open reporting culture for any incidents that took place. Staff were encouraged to raise incidents and managers gave them feedback when appropriate. Staff were aware of their responsibilities to safeguard children and young people from abuse and worked closely with different agencies where appropriate. Recruitment had been a concern within the health visiting service, but we did not see any evidence that this had a negative effect on the care provided.
Care provided to children and young people was evidence based, using NICE guidance, Department of Health research and from advice from specialist centres. Local, regional and national audits were undertaken. Managers shared the outcomes with staff and, where services needed to improve, we saw action plans in place and plans to re-audit. Multidisciplinary and multi-agency working was embedded across the teams. We saw evidence that staff received regular supervision and appraisals.
We received excellent feedback from children, young people and their parents/carers about the care and treatment they received and the staff who provided it. Staff were skilled at communicating with children and young people and treated them with respect and dignity. Staff were friendly, warm, caring and professional. Staff always put the children and young people at the heart of everything they did and always involved them in their care and treatment. Specially trained health visitors and school nurses took part in a rapid response team to support parents in Wiltshire who had experienced the unexpected death of their child. We saw staff were responsive to the needs of children, young people and their families. Interpreting services were used for families where their first language was not English. Robust clinical governance structures were in place. Staff felt supported by their team leaders and managers within the community services.
Overall rating for this core service Good
We rated Great Western Hospitals NHS Foundation Trust as good overall for community inpatient services. This trust provided inpatient care and support at three community hospitals. There were 37 beds on two wards at Chippenham Community Hospital, 26 beds on one ward at Savernake Hospital in Marlborough and 25 beds on one ward at Warminster Community Hospital. Care and support were provided by nurses, healthcare assistants and therapy services including physiotherapists and occupational therapists. Medical cover was provided by visiting consultants and local general practitioners.
Overall rating for this core service GOOD
We judged the overall service provision of end of life care as good. We found the service to be safe, effective, caring, responsive and well-led.
There were systems in place to keep patients safe. There was a good provision of equipment, including syringe drivers and mattresses for patient use in the community. We saw pre-emptive prescribing of anticipatory medications and availability of the ‘just in case’ medications.
End of life care was delivered through evidence based research and guidance. Education programmes had been developed and delivered, new documentation had been successfully introduced to the trust improving the pathway for patients
Patients and relatives spoke highly of the teams of nurses in the community; they were seen as very responsive to their needs. Out of hours there were good resources for staff to access including a 24 hour advice line managed by specialist palliative care nurses at a local hospice.
End of life care was seen as a priority for the trust. There was a clear overarching strategy for the service and plans to improve the delivery of care had already begun to take place with good results. The staff were able to collate evidence and influence change to improve services for patients.