Updated 7 May 2021
Safe and well-led were requires improvement, with effective, caring, and responsive rated as good. The rating of well-led at core service level was good overall, but the rating for trust management, specifically around financial governance, was requires improvement. This led to a combined overall rating for the trust of requires improvement. Safe and well led remained as requires improvement, and caring remained good. The other key questions of effective and responsive improved from requires improvement to good. In maternity services, caring was rated as outstanding, and in urgent and emergency care (A&E) responsive was rated as outstanding.
We rated well-led at the trust as requires improvement because:
- There was a significant failing of financial governance and the board collectively taking ownership of those areas of concern the trust could control and influence. There was a lack of assurance of financial scrutiny by the board. The board were unable to collectively or consistently articulate or explain the financial problems the trust was facing or the deterioration in the financial position emerging in the latter part of this financial year. The board assurance framework did not rate the financial risks at a sufficient level to match the degree of their seriousness. NHS Improvement rated the trust as inadequate for its use of financial resources.
However:
- Beyond the significant financial challenge, the trust’s leadership team had the experience, capacity, capability and integrity to lead the organisation. Leaders were highly visible, approachable and supportive to their staff. The leadership team recognised there were challenges to high quality care and sustainability, although this did not extend to a resolution of the serious financial issues.
- There was an interconnected vision and strategy for the quality of care and services for patients and the local population. The trust was working with local healthcare partners to achieve the priorities for delivering good quality sustainable care, but failing to make inroads and play its part in a system-wide solution to the financial problem.
- The culture of the organisation was strong and centred on people who use services. Staff felt positive and proud to work for the organisation. The leadership team modelled and encouraged compassionate, inclusive and supportive relationships among staff, who felt respected, valued and supported. There was an emphasis in the trust on the safety and wellbeing of staff. Equality and diversity were promoted within the organisation. There were structures, processes and systems of accountability to operate a governance system designed to monitor the service and provide assurance of safe and quality care.
- The operational performance at the trust was meeting most of the national targets or standards for treating patients. It was performing better than the England average in all measures. The trust engaged in a variety of ways with the public and local organisations to plan, manage and deliver services.
- There was a strong culture of reporting incidents to learn and improve. There were systems to improve the service and performance with a focus on continuous learning and quality improvement projects. There was innovation and development through research.
- Urgent and emergency services (also known as accident and emergency services or A&E) improved from requires improvement to good overall. Safe, effective and well-led improved from requires improvement to good. Caring remained as good, with responsive improving significantly from requires improvement to outstanding. In safe, we found people were protected from harm by sufficient numbers of staff, a safely run department, and a team willing to learn and improve. Care was delivered effectively to give patients good outcomes. The caring of patients was delivered with kindness and empathy. Our rating of responsive described the department’s service as outstanding. The service was one of the top in England at meeting the four-hour standard to see and treat patients. Patients were treated as individuals and meeting their needs was part of the values which drove staff. Well-led had improved with a renewed commitment to the service, it’s governance and improvement.
- Medical care was rated overall as good overall. This improved from a rating of requires improvement at our last inspection in 2016. Safe remained as requires improvement but responsive and well-led improved to good. Effective and caring remained as good. In safe, we were concerned about risk assessments and responding to deteriorating patients. There were some issues with cleanliness, tidiness and equipment checking. Patients’ records were not always maintained well enough. However, other aspects of safe had seen improvements. Effective care was provided to give patients good outcomes. Caring was provided with kindness, and patients and those who cared for them were valued as central to the care provided. The service met the needs of people who used it, and responsive was rated as good. There had been considerable work to get people into and out of hospital in the best way possible, although some referral times needed to be improved. The service was well-led and this area rated as good. The management had the skills and experience to lead and govern the quality and safety of care.
- Maternity services were rated overall as good. We previously inspected maternity jointly with gynaecology so we cannot compare our new ratings directly with previous ratings. Safe, effective, responsive and well-led were rated as good. Caring was rated as outstanding. In safe, training, safeguarding, infection risk and medicines were managed safely. Equipment and premises were generally well-maintained, although the premises were ageing and some areas not ideal. The windows were susceptible to leaking in the rain and the lift was at risk from breaking down at times. There were mostly safe levels of staff as recommended by national guidance. Care was effectively provided in line with national guidance and women had good outcomes. Staff were competent and their performance was monitored. Caring was rated as outstanding as feedback from women and their partners was consistently excellent. Women were treated with dignity and respect and emotional support. The service was responsive to the needs of women and their partners. Services were planned to give choice and were available when needed. Managers in the service had the skills and experience to provide a good, high-quality service. There was a positive culture and staff were well supported.
- Services for children and young people improved from requires improvement at our last inspection in 2016 to good overall. Safe stayed as requires improvement. Effective remained good as did caring and responsive. Well-led improved from requires improvement to good. Safe remained as requires improvement as we were concerned about the overall safety of the environment with the necessary admission of children with mental health problems where there were no beds available to them in specialist mental health services. Not all staff had updated their mandatory training and some patient records needed to be better. However, staff knew how to protect children from abuse and there were enough staff to support them. Incidents were managed well and the service was willing to learn. Care was effective and children and young people had good outcomes. Caring was provided with kindness and compassion to both children, young people and their families. The service was responsive to meet the needs of the population. Well-led had improved with managers who had the skills to run a service with a recognised commitment to children and young people. There was a positive culture and shared values.
- End of life care was rated overall as good. This improved from a rating of requires improvement at our last inspection in 2016. Safe dropped one rating to requires improvement due to issues with recording of mental capacity assessments and decisions around resuscitation. Not all risk assessments were being completed and there was no policy or standard operating procedures for the use of syringe drivers. However, staff were well-trained, kept patients safe, most patients’ records were good, and there was a safe level of staff. Effective remained good with patients receiving good outcomes and care and treatment based upon national guidance. There was good multidisciplinary working. Caring was good, with staff providing compassionate and emotional support. Responsive remained as good with the service committed to meeting the needs of the population and caring for them as individuals in the last phase of their lives. Well-led had improved to good with renewed leadership. The governance of the service had improved, although there remained some work to do.
- On this inspection we did not inspect surgery, critical care, or outpatients. The ratings we gave to these services on the previous inspection in 2016 are part of the overall rating awarded to the trust this time.
- Our decisions on overall ratings take into account, for example, the relative size of services and we use our professional judgement to reach a fair and balanced rating.
Our full Inspection report summarising what we found and the supporting Evidence appendix containing detailed evidence and data about the trust is available on our website – www.cqc.org.uk/provider/RA4/reports.