Hampshire Hospitals NHS Foundation Trust

Hampshire Hospitals NHS Foundation Trust was established in January 2012 as a result of the acquisition by Basingstoke & North Hampshire NHS Foundation Trust of Winchester & Eastleigh Healthcare Trust. The trust provides acute hospital services to approximately 600,000 patients in Basingstoke, Winchester, Andover and surrounding areas in Hampshire and West Berkshire.

The trust provides services from Andover War Memorial Hospital, Andover, Basingstoke and North Hampshire Hospital, Basingstoke and the Royal Hampshire County Hospital, Winchester. Outpatient and assessment services are provided from Alton, Bordon and Romsey Community hospitals, and the Velmore Centre in Eastleigh.

We undertook this inspection of Hampshire Hospitals NHS Foundation Trust as part of our comprehensive inspection programme. The trust was in band 6 based on our Intelligent Monitoring information system.

Trusts have been categorised into one of six summary bands, with Band 1 representing highest risk and Band 6 the lowest risk.

The inspection was announced and took place from 28 – 31 July 2015, with additional unannounced inspection visits on 13 and 14 August 2015. The inspection team included CQC senior managers, inspectors and analysts, doctors, nurses, allied healthcare professionals, ’experts by experience’ and senior NHS managers.

We inspected the following core services: urgent and emergency care, medical (including older people’s) care, surgery, critical care, maternity and gynaecology, services for children and young people, end of life care, and outpatient and diagnostic services.

Overall, we rated this trust as ‘good’. We rated it ‘outstanding’ for providing caring services and ‘good’ for effective, responsive and well-led service. We rated it as ‘requires improvement’ for safety.

Overall, we rated Andover War Memorial Hospital as ‘requires improvement’. We rated Royal Hampshire County Hospital and Basingstoke and North Hampshire Hospital as ‘good’.

Our key findings were as follows:

Is the trust well-led?

• The trust had a five year strategy that aimed to deliver high quality safe patient care through transforming services. There was a focus on emergency care to build a new critical treatment hospital and deliver local care in the general hospitals and integrated health and social care closer to home. There were operational plans to focus on priorities and immediate capacity issues. However, clinical services did not have strategic plans to develop in the short and medium term.
• Governance arrangements were well developed at trust, division, clinical service and ward level. The trust had a comprehensive integrated performance report to benchmark quality, operational and financial information. Clinical quality dashboards were available from board to ward to improve the quality of information, monitoring and reporting. Risks were appropriately managed and escalated to the board, although this varied in some areas.
• The trust had benefitted from the duration of the working relationships amongst its leadership team. Whilst challenge and reflective scrutiny had continued, the maturity of the organisation was such that there could be an unconscious way of working where structures were sometimes less significant. The leadership team had recognised the need for succession planning and an external assessment of its governance arrangements. The trust needed to improve its use of internal audit and clinical audit to review governance arrangements and provide assurance around risk and effectiveness.
• The leadership team showed commitment, enthusiasm and passion to develop and continuously improve services. The trust could demonstrate improvement against many of its quality priorities, although the level of avoidable harms, such as falls and pressure ulcers, remained the same.
• Staff at every level told us about the visibility and support of the chief executive. Staff were positive about working for the trust and the quality of care they provided. Many felt engaged with the trust priorities although some were concerned that they were not being listened to, and there was low morale in places based on staffing issues and management decisions.
• The culture of the organisation was different across the three sites. The merger or harmonisation of hospitals (the trust preferred term) was acknowledged as work in progress but was seen as successful overall. There was a difference in confidence with the staff at Andover War Memorial Hospital, Royal Hampshire County Hospital (RHCH), Winchester and Basingstoke and North Hampshire Hospital (BNHH). There had also been variable progress with integrated working across the three sites. The trust was sighted on priority areas where patient safety, clinical effectiveness and operational risks might occur.
• There was a focus on improving patient experience and public engagement to develop services. The public were involved in nominating staff that demonstrated excellent practice through the WOW! Award scheme.
• The trust supported and encouraged staff to innovate and improve services.
• Cost improvement programmes were identified with clinical staff and were assessed for risks and monitored. Savings and productivity, however, were not being delivered as planned, mainly because of the cost of emergency admissions and the trust was in a managed financial deficit.
• The trust was in discussion with commissioners about plans for the new critical treatment hospital. Whilst the clinical model was understood there was concern about its affordability and sustainability. There was ongoing discussion and debate about the viability of different options and the risks involved. A decision had yet to be made.

Are services safe?

• Staff were encouraged to report incidents and there was learning from incidents to improve the safety of services locally and across the trust. However, information sharing needed to improve for some services at Andover War Memorial Hospital.
• 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.
• Clinical areas, such as wards, theatres and clinics were visibly clean with appropriate cleaning schedules.
• Staff followed infection control procedures and these were monitored, although this was not consistent and needed to improve in some areas.
• Medicines were appropriately managed and stored. However, fridge temperatures were not being regularly checked and monitored on some wards.
• Anticipatory medicines (medicines prescribed for the key symptoms in the dying phase ie pain, agitation, excessive respiratory secretions, nausea, vomiting and breathlessness) were prescribed appropriately.
• Equipment was checked and stored appropriately in most areas but this needed to improve on some wards, specifically for resuscitation equipment.
• Overall, staff had a good understanding of safeguarding adults and children.
• More staff needed to complete mandatory training.
• Patients’ were assessed and monitored appropriately, for example, risk assessments were complete. However, the early warning score needed to be used consistently in surgery, and a tool was required for outpatients, for patients whose condition might deteriorate.

• The hospital had a higher than expected number of avoidable harms (pressure ulcers and falls) against their own targets. The trust was taking action to improve this, for example, care bundles were introduced to appropriately assess and treat patients,

• Critically ill children attending the emergency department were immediately referred to a paediatrician. There was a protocol for the transfer of critically ill children to a specialist care from the Southampton and Oxford retrieval team (SORT). The SORT team would provide specialist staff to support the child during the transfer.

• Medical staffing levels across the hospital were appropriate. National recommendations were followed, for example, for consultant presence in the emergency department, maternity, critical care and end of life care. There was consultant presence in the hospital over seven days with the exception of surgical services; there was 24 hour consultant cover arrangements across all services. Consultants in children and young people services were working additional sessions because of vacancies with junior doctors at middle grade level. This additional working was not sustainable in the long term.

• Nursing staffing levels were identified at trust level using an appropriate acuity tool. Planned staffing levels across all areas were higher than minimum recommendations. The hospital had a significant number of vacancies particularly in emergency medicine, medical and older people’s care, surgery and children’s and young people’s services. Staffing levels were monitored and action was taken to fill vacancies from bank staff. Agency staff were not used. However, some medical and surgical wards did not always meet safe staffing levels. Nursing staff were coping by working longer hours, sharing staff or staff skills across shifts. Patients on these wards told us their needs were being met. The trust was implementing actions to mitigate for example, by developing skills in health care assistants and having ongoing recruitment campaigns, including employing staff from overseas. There was also innovation in developing new roles for staff, for example, majors practitioners in the emergency department and advanced critical care practitioners. However, we found in some areas, patient needs were not being met.

• Midwifery staffing levels did not meet national recommendations but staff worked flexibly and could provide one to one care for all women in labour.

• Radiographers at Royal Hampshire County Hospital worked alone overnight covering imaging services for the hospital and the emergency department. Radiographers reported a heavy workload and raised concerns about manual handling issues. Between 10.00pm and 8am, radiology was supported by an overnight outsourced radiologist service. Staff identified delays in the process to authorise request and provide advice on imaging which meant delays in the patient diagnosis.

• The new regulation, Duty of Candour, states that providers should be open and transparent with people who use services. It sets out specific requirements when things go wrong with care and treatment, including informing people about the incident, providing reasonable support, giving truthful information and an apology. The trust monitored duty of candour through their online incident reporting system. Overall, senior staff we spoke with were aware of duty of candour and talked about the importance of being open and transparent with patients and their families.

Are services effective?

• Staff were providing care and treatment to patients based on national and best practice guidelines. In some areas guidelines had been unified across the trust for consistency of care.
• Services were monitoring the standards of care and treatment. Patient outcomes were similar to or better than the England average. There were action plans to address where outcomes were worse when compared to the England average.
• Patients who had suffered a stroke would be taken to the Royal Hampshire County Hospital as this was the designated receiving unit for the specialist treatment of stroke in Hampshire. From October 2014 to December 2014, the hospital performed better than other trusts for meeting standards for specialist assessments, thrombolysis and provision of physiotherapy and occupational therapy and discharge processes. The hospital was similar to other trusts for care on the stroke unit, multi-disciplinary working and standards of discharge standards. The hospital performed significantly worse than other trusts in providing speech and language therapy and scanning.

• Patients with chest pain were taken to Basingstoke and North Hampshire Hospital as the designated centre for specialist treatment if possible. The hospital’s performance was better than national average for patients with non-ST segment elevation myocardial infarction (a type of heart attack) who were seen by a cardiologist or a member of their team and treated on a cardiac ward or unit. The hospital performed below the national average for patients being referred for or had angiography.

• Patients received good pain relief across all services.
• Patients, particularly older patients, were supported to ensure their hydration and nutrition needs were met.
• Staff were supported to access training. Many staff had a high level of competency having undertaken specialty specific qualifications. There was evidence of regular staff appraisal although clinical supervision varied.
• Staff worked effectively in multidisciplinary teams to centre care around patients. This included working with GPs, community services, and other hospitals. There were innovations in electronic records and the use of video conferencing in end of life care that enabled information to be shared about patient’s clinical needs and preferences across the trust, and with community and GP services. However, paediatric inpatient physiotherapy was not sufficient for children and young people with Cystic Fibrosis at the weekends and this was of concern.
• Seven-day services were well developed, particularly for emergency patients. There was support from therapists: pharmacy and diagnostic services were less well developed.

• Staff had appropriate knowledge of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards to ensure that patients’ best interests were protected. Guidance was available for staff to follow on the action they should take if they considered that a person lacked mental capacity. Notification of Deprivation of Liberty Safeguards applications were correctly submitted to the Commission. However, the capacity assessments were not always documented or regularly reviewed in patient care records.
• ‘Do Not Attempt Cardio Pulmonary Resuscitation’ (DNACPR) forms were not always appropriately completed and did not include, for example, an assessment of the patient’s mental capacity.

Are services caring?

• Staff were caring and compassionate and treated patients with dignity and respect. There was a culture in the hospital of understanding and responding to patient’s individual needs. This covered clinical and non-clinical staff such as porters and housekeeping staff who recognised the importance of their role in providing good quality care.
• Patient feedback was overwhelming positive across all services.
• We observed outstanding care for critical care patients, children and young people, patients having end of life care and patients attending outpatient and diagnostic imaging services. The staff had an ethos of providing person centred care and developed trusting relationship with patients and their families.
• Staff maintained patient’s confidentiality, privacy and dignity in all areas, although the layout of bays in a few areas may have compromised patient’s dignity at times.
• Patients and their relatives felt involved in their care and treatment, staff provided information and explanations in a way patients could understand. Patients felt that their views and considerations were listened to and acted upon.
• Records of conversations were detailed on patient records. This meant staff always knew what explanations had been provided and reduced the risk of confusing or conflicting information being given to relatives and patients.
• Patients and their families were supported by staff emotionally to reduce anxiety and concern. There was also support for carers, family and friends for example, from the chaplaincy, bereavement services for patients having end of life care, and counselling support where required.
• Data from the national surveys demonstrated that the hospital was similar to other trusts. Patients were very satisfied and would recommend the care they received.

Are services responsive?

• Services were being planned to respond to increases in demand, staff capacity and patient needs. There was some innovation in models of care, for example, ambulatory care, acute assessment unit and early supported discharge. There was also joint work with partners, for example, to in-reach services for psychiatric assessment. Children’s and young people services had reduced the number of beds to respond to staffing issues. Other areas were working on how to increase capacity.

• Bed occupancy in the trust was below the England average of 88% although this was higher on surgical wards. It is generally accepted that at 85% level, bed occupancy can start to affect the quality of care provided to patients, and the orderly running of the hospital.

• The trust was not meeting the national emergency access target for 95% of patients to be admitted, transferred or discharged within 4 hours. Ambulance handovers over 30 minutes were often delayed and patients often had to wait in the emergency department for admissions.
• During our inspection, there were very few medical patients on outlier wards (a ward that is not specialised in their care). Information from the trust demonstrated that these patients were regularly assessed.
• Patient bed moves happened frequently, including at night. Staff were ensuring that patients with lower dependency needs were moved and patients had not expressed concern about their moves.
• The trust was achieving the 31-day cancer waiting time diagnosis-to-treatment target and the 62-day referral-to-treatment target, although this had not been met in June 2015.
• The trust was achieving the 18-week referral-to-treatment time target for medical patients and some surgical patients. The target was not being achieved in orthopaedics and ophthalmology.
• The majority of patient who had cancelled surgical procedures for non-clinical reasons were re-booked for surgery within 28 days.
• The trust was meeting national waiting times for diagnostic imaging within six week, outpatient appointments within 18 weeks and cancer waiting times for urgent referral appointments within 2 weeks and diagnosis at one month and treatment within two months.
• The trust cancellation rate for appointments was 10%; the England average was 7%. Many of these clinic cancellations were at short notice. The reasons for this varied and included cancellation for staff sickness, training and annual leave. There was a plan to address this but this was in development. Patients were not appropriately monitored to ensure the timeliness of re-appointments
• Women were able to make choices about where they would like to deliver their babies. They had access to early pregnancy assessment and their preferred ante-natal clinics. Women in the early stages of labour had access to telephone support.
• Patient discharge was effectively supported. Patients were regularly reviewed and discharge coordinators worked to improve the discharge of patients with complex care needs. There was a discharge lounge for medical patients and early supportive discharge for stroke patients. The trust had problems with increasing numbers of delayed transfers of care for community services, and was working with partners to improve this.
• Support for patients living with dementia was well developed, for example, there was specialist support, appropriate assessment, a sunflower symbol was used and staff had good awareness and training. There was good practice across the trust for supporting patients living with dementia and their carers.
• Support for people with a learning disability needed further development. Although there was support for carers, the hospital needed a flagging system or passport to identify and support patients and some staff identified the need for further training.
• The trust offers a number of one- stop clinics. The breast unit, for example, offers appointments to patients within two weeks following GP referral. The referrals were initially received into the central booking office and prioritised by consultants. Patients who attended the one stop clinics would see a clinician, have a biopsy taken and see a radiologist if required. If a cancer diagnosis was suspected, patients were told before leaving the clinic and an appointment given to discuss the outcome and treatment options. This unit provided a responsive service for patients who were anxious in relation to a potential cancer diagnosis.
• Patients having end of life care were identified by a butterfly symbol so that staff were aware of their needs and those of their family.
• There was a hospital at home service to deliver care to those patients identified as being in the last days or hours of life. The service was 24 hours and seven days a week. Multidisciplinary team working and innovations in electronic records and the use of video conferencing in end of life care also facilitated rapid assessment and access to equipment.
• Patients having end of life care had multi-disciplinary care focused on their physical, mental, emotional and social needs. Patients could have a rapid discharge to home arranged within 24 hours. However, there were delays to the rapid and fast track discharge processes (within 48 hours) and processes were being improved to meet national standards.
• All wards we visited provided care for patients in single sex accommodation bays, in line with Department of Health requirements.

• Complaints were handled appropriately and there was evidence of improvements to services as a result. Some services, however, were not responding to complaints in a timely way.

Are services well-led?

• All services identified the plans to build a new Critical Treatment Hospital as the overall strategy for the trust and there were in-depth plans towards this across services. However, some services did not have specific strategies and plans in the short and medium term to respond to priorities. Some consultants identified concerns with the plans for the new hospital.
• Services had effective clinical governance arrangements to monitor quality, risk and performance. The outpatients department needed to further improve processes to manage risk and quality.
• Many staff told us overall they had good support from the local clinical leaders and staff engagement was good.
• Many staff identified the visibility and support of the chief executive of the trust.
• Joint working between Basingstoke and North Hampshire Hospital and Royal Hampshire County Hospital varied. This was important to improve standards, share good practice and develop efficient and effective services across the trust. This was well developed in the emergency department, critical care and end of life care. Some services at Andover War Memorial Hospital reported feeling ‘disconnected’ from the wider trust.
• The leadership for end of life care was outstanding. There were robust governance arrangements and an engaged staff culture all of which contributed to driving and improving the delivery of high quality person-centred care. This was an innovative service with a clear vision and supportive leadership and board structure.
• Patient engagement was mainly through survey feedback: however, there was some innovation, for example the use of social media in maternity, afternoon tea sessions with stroke patients and their families and ‘through your eyes’ a listening event for surgery.
• The trust had a WOW Award scheme to recognise outstanding service. Staff could be nominated by patients or their colleagues. Recognition through the WOW Awards had led to high levels of staff satisfaction throughout the service

• Ideas to innovative and improve services were encouraged. There was participation in research, quality improvement projects, and innovation in developing new roles for staff, such as the Majors practitioners, volunteers caring in dementia, advanced critical care practitioners.

We saw many areas of outstanding practice including:

• The trust is one of only two designated specialist treatment centres in the country for treatment of Pseudomyxoma. This is a very rare type of cancer that usually begins in the appendix, or in other parts of the bowel, the ovary or bladder. The hospital has treated more than 1000 such cases. The diverse multidisciplinary team has developed the skills to help patients through this extensive treatment, and share their knowledge on international courses and conferences.
• Through audit, surgeons working at the trust have changed practice world-wide, such as new techniques for the biopsy on operable tumours and the benefits of waiting six weeks after completing chemotherapy before performing liver resection.
• Every medical and care of elderly ward had an activity coordinator who planned and conducted different activities for patients after consulting them. The activities included a range of things such as arts and craft, music, dance, group lunches and movie time.
• GPs had access to electronic information held by the trust. This meant they were able to access electronic discharge summaries with up to date information available about care and treatment patients had received in hospital.
• A LEGO brick model, designed by a play leader, was used to prepare children for MRI scans. The model was successful in reducing children’s fears and apprehension. The model had been adopted for use in other hospitals.
• The trust was developing innovative new roles for staff, for example, majors practitioners in the emergency department and advanced critical care practitioners.
• Afternoon tea sessions were held for patients and their relatives in the stroke wards. This gave patients an opportunity to share their experiences, peer support and education. The session was also attended by a member of the stroke association team who delivered educational sessions related to care after stroke. Patients were also given information about support available in the community.
• A nurse-led eight bedded day unit in the admissions and discharge lounge for patients who required certain medical interventions. Patients were referred to this service by the medical consultants and this service was helping to meet needs of patients who required medical intervention without prolonging their stay in the hospital. Patients were highly complimentary about this service.
• When patients with complex needs on care of elderly wards were discharged to their new home, they were escorted by a member of nursing or therapy staff who spent up to an hour with patients in their new home. This had helped in offering elderly patients emotional support.
• The early supported discharge team helped stroke patients for up to six weeks following their discharge from the hospital. The staff felt that this gave continuity of care and supported the patients in achieving their goals following the discharge.
• Once a week the librarian attended the ward round in order to source relevant literature to assist the professional development of staff.
• Critical care career pathways were developed to promote the development of the nursing team.
• The critical care unit had Innovative grab sheets that detailed the essential equipment to care for each patient in the event the unit had to be evacuated. These included pictures of the essential equipment, so non-clinical staff such as portering staff could help collect the equipment ensuring medical and nursing care of patients was not interrupted.
• The breast care unit is a fully integrated multi-disciplinary unit that was pioneering intraoperative radiotherapy for breast cancer at the Royal Hampshire County Hospital.
• Kingfisher ward had activity coordinators who planned and conducted different activities for patients after consulting them. There was a range of activities offered, including arts and crafts, music, dance, group lunches and movie time.
• Pregnant women were able to call Labour Line which was the first of its kind introduced in the country. This service involves midwives being based at the local ambulance operations centre. Women who called 999 could discuss their birth plan, make arrangements for their birth and ongoing care. The labour line midwives had information about the availability of midwives at each location and were able to discuss options with women and their partners. Labour Line midwives were able to prioritise ambulances to women in labour if they were considered an emergency. The continuity of care, and the rapid discharge of ambulances when they are really needed, have been two of the main benefits to women in labour. The Labour line had recently won the Royal College of Midwives Excellence in Maternity Care award for 2015 and they were also awarded second place in the Midwifery Service of the Year Award.
• The specialist palliative care team provided a comprehensive training programme for all staff involved in delivering end of life care.
• The cardiac palliative care clinic identified and supported those patients with a non-cancer diagnosis who had been recognised as requiring end of life care.
• The use of the butterfly initiative in end of life care promoted dignity and respect for the deceased and their relatives.
• There was strong clinical leadership for the end of life service with an obvious commitment to improving and sustaining care delivery for those patients at the end of their lives.
• All staff throughout the hospital were dedicated to providing compassionate end of life care.
• The Countess of Brecknock Hospice contacted bereaved relatives following the death of a relative and sent a card on the anniversary of the patient’s death.
• The hospice at home service was pro-active in supporting patients in their own home.
• All staff throughout the Countess of Brecknock Hospice were dedicated to providing compassionate end of life care.

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

Importantly, the trust must ensure that:

• Patients in the ED are admitted, transferred or discharged within national target times of four hours.
• There is an appropriate system to identifying patients with a learning disability.
• Nurse staffing levels comply with safer staffing levels guidance.
• The emergency resuscitation trolleys are appropriately checked and are sealed or tagged.
• Medicines are appropriately managed and stored in surgery.
• Controlled drugs in liquid form are managed and stored appropriately in all the medical wards
• The early warning score is used consistently in surgery and a system is developed for use in outpatients.
• Venous thrombo-embolism assessment occurs on admission for surgical patients.
• Resuscitation equipment is appropriately checked and items are sealed and tagged.
• Staffing in radiology complies with guidance so that staff do not have heavy workloads, and manual handling risks and staff have access to appropriate advice.
• There is effective partnership working so that children and young people with mental health needs (CAMHS) have timely assessment and care reviews.
• Children with cystic fibrosis are supported by appropriate paediatric physiotherapy.
• The outsourced diagnostic imaging service is appropriately monitored and managed to reduce delays.
• There are appropriate processes and monitoring arrangements to reduce the number of cancelled outpatient appointments and ensure patients have timely and appropriate follow up.
• MIU staff have access to up to date approved Patient Group Directions (PGDs)
• MIU staff receive update mandatory training in basic life support and infection control
• staff said
• Safeguarding checks are consistently completed and recorded.
• There is a clear hospital protocol for responding to a collapsed patient in an emergency at Andover War Memorial Hospital.
• There is appropriate security on site for the protection of staff and patients in the MIU at Andover War Memorial Hospital.
• Leadership concerns in the MIU are addressed and there is effective leadership from the nurse clinical lead and lead consultant to monitor and maintain clinical standards.
• There is an effective system to identify, assess, monitor and improve the quality and safety of the MIU, the day care unit and outpatient services.

The trust should

• Develop clinical service strategies that support planning, cross site working and the sustainability of services.
• Continue plans for the harmonization of services across hospital sites to ensure consistency of service, staff confidence and opportunity for innovation across hospital sites.
• Ensure governance arrangements are formally evaluated and action is taken around areas of risk and effectiveness.
• Implement recommendations as planned from the board evaluation report including implementation of HR representation on the board and improving external relationships.
• Ensure all staff feel appropriately engaged with plans for the new critical treatment hospital, and clinical models are agreed.

Professor Sir Mike Richards

Chief Inspector of Hospitals