The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust provides healthcare for the residents of Bournemouth, Christchurch, East Dorset and part of the New Forest. It serves a population of around 550,000, and this rises during the summer. Some specialist services cover a wider catchment area, including Poole, the Purbecks and South Wiltshire.
The trust has two main locations: Royal Bournemouth Hospital and Christchurch Hospital. These are located about three miles apart on the South Coast. Most of the acute services are provided at Royal Bournemouth Hospital.
The trust has been inspected five times by CQC since it was registered in October 2011. It was in breach of the Health and Social Care Act 2008 in relation to the management of medicines in September 2011, but this was resolved in May 2012.
At the inspection in October 2013, children’s care, midwifery, critical care and end of life care services at the hospital were good. (The children’s service is limited to eye operations and the maternity service is a small midwifery-run unit.) In all services across the hospital, most staff were committed to the trust and eager to give good care to patients. Patients were complimentary about the care they received and the professionalism of staff on surgical services.
However, a number of services were not always safe, effective, responsive, caring or well-led. In particular we found that medical care (including care older people’s care) was inadequate. There were widespread and significant negative views from patients and staff. The trust’s Board had not focused sufficiently on improving or recognising these failures, or the urgent need to improve patient care. Other services requiring improvements to patients’ experience included A&E, surgical services and outpatients.
We were told about basic nursing care not being given to patients, in particular on medical care Wards 3 and 26. We heard about a patient who had had fluids and food restricted in error. We also heard from five patients who told us they had been left to wet or soil their beds.The hospital had a high occupancy rate and there had been ongoing use of escalation beds when a ward or unit was full. This was dangerous and could not meet any patient’s needs.
The trust did not at this time employ enough staff, even though it was fully aware that nearly all its beds were occupied all the time. We were told that there were 135 nursing and healthcare assistant vacancies at the end of September 2013. While 65 posts had been filled by late October 2013, the benefit to existing staff had not yet materialised, in particular for medical services. Some patients were still not receiving the care they needed in a timely manner, and there was an ongoing high risk of this continuing.
Patients who had suffered a stroke did not always have the fast access urgent treatment on the specialist unit that they needed.
Other issues we found were:
- Care planning and evaluation did not always contain all relevant information, and staff on duty did not always know the specific care needs of people.
- Mandatory training for staff was not always delivered on time, or they were not always suitably trained for the areas in which they might work, for example dementia care and assessing whether a patient is able to swallow.
- Security arrangements in A&E left staff feeling vulnerable.
- We found the trust overall was not ensuring effective leadership and governance across the hospital.
At the follow up inspection in August 2014, we found that significant improvements had been made and the issues found in October 2013 had been addressed.
The trust had agreed a two year organisation development plan with a focus on improving quality. A revised organisational structure was being implemented, with a strong emphasis on clinical leadership. This was supported by leadership training for all levels of staff. The governance systems had been strengthened at all levels and the Board members and senior management team were receiving more robust assurance of quality in all areas. We found there had been significant steps towards creating an open , transparent and learning culture at all levels of the organisation. The complaints policy and processes had been reviewed and the Trust was working more closely with local Healthwatch and patients to listen to their views and experiences, in order to make improvements.
The introduction of an Elderly Care Directorate with new assessment ward and pathways had improved the care for older people and the flow of patients through the hospital.
The unsafe escalation beds were no longer in use.
We found increases in staffing levels and increased support for junior doctors. The appointment of clinical matrons and support for ward sisters to focus on leadership and supervision of staff on the wards now supported planning and the delivery of safe and effective care. The speed of access to diagnostics and the stroke unit had improved, but the trust still needed to review the out of hours medical cover to ensure these patients had access to timely specialist assessment and treatment once on the Stroke Unit.
Improvements on A&E included improved security arrangements. We found evidence of training having a positive impact on patient care, particularly for those living with dementia. The trust was aware of the need for more robust patient pathways for some patients admitted to A&E and was in discussion with Commissioners and local NHS partners to make those improvements.
Staff were proud of the improvements achieved since the last inspection but recognised there was more to be done to ensure the changes were embedded and the quality of services sustained.