Archived: The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust

The Royal Bournemouth & Christchurch Hospitals NHS Foundation Trust has two hospitals. The trust gained foundation status in 2005 and provides services, to a population of 550,000 in the Dorset, New Forest and south Wiltshire areas, which rises in the summer months due to an influx of visitors to the area.

The Royal Bournemouth Hospital is larger of two hospitals and has approximately 600 inpatient beds and 123 day case beds. The hospital provides urgent and emergency care, medical care, surgery, critical care, end of life care, outpatient and diagnostic services. There is a limited gynaecology service and a midwifery led maternity unit, including a three bedded birthing unit and community midwife service. The children and young person’s service is limited to eye surgery and outpatients. The main centre for obstetrics and gynaecology and paediatric services is at a nearby NHS hospital in Poole

Christchurch Hospital provides a range of services including the Macmillan Unit with 16 end of life care beds, a day hospice and a community palliative care team.  There are a range of outpatient clinics including children’s dermatology out patients, and an x-ray service. There is a large day hospital providing rehabilitation service. No other services are provided at Christchurch Hospital. A major redevelopment programme is underway, which will provide refurbished facilities for these services. At the time of inspection work some of the outpatient and x-ray departments were in temporary accommodation.

We inspected the 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 the highest risk and Band 6 the lowest risk.

We carried out an announced inspection visit to the hospital 20 -22 October 2015 and additional unannounced inspection visits 27 October, 4 and 9 November 2015. The inspection team included CQC managers, inspectors, and analysts. Doctors, nurses, allied healthcare professionals, senior NHS managers and ‘experts by experience’ were also part of the team.

We inspected the following core services at The Royal Bournemouth Hospital: urgent and emergency care, medical care, surgery, critical care, maternity and gynaecology, children and young people, end of life care, outpatient and diagnostic services. We inspected two core services at Christchurch Hospital: end of life care; and outpatients and diagnostic imaging, which included the day hospital. We also inspected children’s outpatient dermatology service. Detailed findings on children’s outpatient dermatology service at Christchurch Hospital are included under The Royal Bournemouth Hospital Report under children and young people’s core service.

Overall, we rated this trust as ‘requires improvement’. We rated it ‘good’ for providing caring services and ‘requires improvement’ for safe, effective, responsive and well-led services. The trust was rated as ‘requires improvement’ for being well led overall.

Overall we rated Royal Bournemouth Hospital as ‘requires improvement ’. The hospital was rated as requires improvement for providing safe, effective, responsive and well led care. The hospital was rated ‘good’ for caring. We rated urgent and emergency care services, medical care and maternity and gynaecology services as requires improvement.  We rated surgery, critical care, services for children and young people, end of life care and outpatient and diagnostic imaging as good.

Overall we rated Christchurch Hospital as ‘good’. The hospital was rated as good for providing safe, effective, caring responsive and well led end of life care services, and outpatient and diagnostics services.

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 and effective patient care through transforming services. The strategy would be determined by the outcome of the Dorset clinical review. The strategic context of the trust was well analysed and explained, and the trust had planned and prepared for one of two options. To be the main emergency care site or a site for planned (scheduled) care.
• Governance arrangements were developed at the trust and the pace of change had quickened following CQC inspections in 2013 and 2014. There was a better focus on quality at safety and clinical dashboards were used at trust, division, clinical service and ward level.  However, governance needed to improve in some clinical areas.  The trust needed to improve monitoring arrangements in places as well as ensure action was taken and embedded based on the monitoring of quality and safety. Risks needed to be better managed to identify and respond to staff concerns, to escalate risks to the board and for the board to focus on, and differentiate, high level clinical risks and strategic and operational risks as part of its assurance framework. The trust could demonstrate some progress and improvement against its quality improvement projects.
• The leadership team showed commitment to develop and continuously improve services and were planning a new inclusive leadership and management style. A collective clinical leadership model was the long term strategy and culture change. This was in its early stages and was being developed with staff.
• Relationships between the trust board and some council of governors had deteriorated and needed to improve.
• Staff were positive about working for the trust and the quality of care they provided. They were positive about the trust focus on improving its culture to one that was more open and transparent and focused on patients. This was described as in progress. Staff identified the need for increased visibility of the trust board and senior managers and wanted better engagement on strategic and operational issues, particularly when changes were made that had affected their working practice.
• Partners in system resilience identified that the trust was working more effectively in collaboration but sometimes, under pressure, there was a tendency to look for external action rather than identify what they could themselves improve.
• Patient surveys and focus groups were used to improve services although there was less evidence of patient and public engagement to develop services overall.
• The trust supported and encouraged staff to innovate and improve services. Cost improvement programmes were identified with clinical staff, and these were assessed and monitored to reduce the impact on quality and risk. The trust had invested in staff to ensure safer staffing levels and had plans to deliver expected savings and reduce their financial deficit.

Are services safe?

• Staff were encouraged to report incidents. However, this process was not embedded in all areas. Some staff did not always receive direct feedback. There was investigation and learning to improve the safety of services.
• The rate of incidents (NRLS) per 100 admissions was below the England average with 98% of incidents being low or no harm incidents. There were 47 serious incidents in the 12 months to April 2015, of which four were Never Events. The rate of serious incidents was below the median of all trusts (2013/14). The majority of serious incidents were pressure ulcers and falls. In October 2015, the trust was at 91% for harm free care and not meeting its own targets (95%).
• The initial clinical assessment of emergency patients arriving at the emergency department during the day was timely within the national standard of 15 minutes. However, at night the assessment was not timely or appropriately performed and this put some patients at risk.
• Patients were assessed and monitored by nursing staff using electronic hand held devices. However, some staff did not always complete risk assessments in a timely and effective manner whilst getting used to the new nurse electronic risk assessment process.
• The early warning score system needed to be used more consistently for the escalation of patients whose condition might deteriorate.
• In some operating theatres, staff did not follow the five steps for surgical safety consistently or accurately, to minimise the risks of patient harm.
• There was not an up-to-date protocol to remove a collapsed woman from a birthing pool in the event of unforeseen complications during labour or birth. Staff were not consistently able to describe emergency procedures in the birth centre.
• Medicines were not consistently managed safely across the hospital. In some areas medicines were not stored securely, or stored safely at correct temperatures. Staff did not always follow trust policy when administering medication or destroying controlled drugs.
• Staff generally adhered to infection control procedures, but there were some lapses in hand hygiene and some practices did not fully support effective infection control and prevention.
• Some clinical areas such as emergency department and critical care unit were cramped. The corridor between Derwent Suite and the main hospital, used for transfers, was not suitable for patients. Most wards and clinical areas were clean but we found dust and cobwebs in some operating theatres.
• Equipment was checked and stored appropriately in most areas but this needed to improve in the emergency department, critical care and some medical and surgical wards, specifically for emergency and transfer equipment.
• Overall, staff had a good understanding of safeguarding adults and children
• More staff needed to complete mandatory training, compliance was below the trust target in most areas.
• Although there had been recruitment of nursing staff, vacancy levels were still high on some wards, and there was evidence that requests for additional staff to provide cover were not always met. On occasions there was a lack of consideration of the skill mix when agency and bank staff were covering vacant shifts. Wards that had a high number of temporary staff on duty did not have sufficient numbers of permanent staff to provide guidance to the temporary staff about meeting patient individual needs in a safe manner.
• There was appropriate medical staffing levels in most areas, although consultants in emergency departments were not present in the department for 16 hours a day as recommended by the Royal College of Emergency medicine. The critical care unit was left without medical cover after 11pm if the one junior doctor was called for an emergency elsewhere.
• 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.
• Senior clinical staff were aware of the Duty of Candour regulation and the importance of being open and transparent with patients and families. The considerations and documentation around this regulation needed to be happen in sexual health services, on one occasion.
• The majority of do not attempt cardio pulmonary resuscitation (DNACPR) forms had been appropriate completed.

Are services effective?

• Mortality rates in the trust were within expected range. Mortality rates had improved (downward trend) over the last 18 months. There was no difference between weekend and weekday mortality rates. Seven day services in emergency medicine, acute medicine gastroenterology, cardiology, and critical care supported this positive trend
• The treatment and care provided in most services took account of current evidence-based guidelines. However, evidence-based guidelines for the care and treatment of patients in the emergency department were not always followed.
• The end of life care services had introduced personalised care plan for the last days of life (PCPDL). Wards we visited were aware of this documentation which was a replacement following the national withdrawal of the Liverpool Care Pathway in July 2014. The trust was piloting AMBER Care Bundle on some wards.
• Most services participated in national and local audits which showed improving and good outcomes for patients. Emergency care patient outcomes varied and the results of audits were not always used to improve treatment techniques. The midwifery service did not collect information on patient outcomes and there was no programme of audits in place.
• Pain relief, drinks and food were not always given in a timely manner in the emergency department. Patients received good pain relief and nutrition across all other services.
• Most patients had access to services seven days a week and were cared for by a multi-disciplinary team working in a co-ordinated way. However the allocation of multidisciplinary support to the critical care unit, including pharmacy and physiotherapy, was lower that recommended. The wider multidisciplinary team did not attend the consultant led ward round on the unit.
• The critical care unit was working with the Specialist Nurses in Organ Donation (SNODs) to improve organ donation rate.
• There was a low staff appraisal rate following the introduction of a new system, we found its use was improving and most staff completed training relevant to their roles. There was a comprehensive training programme for medical staff but little evidence of nursing staff competency training in the emergency department. Not all staff had access to clinical supervision
• Access to information was mostly effective. In some services patient information was held in a variety of formats which meant it could sometimes be difficult to use and time consuming to find. Electronic patient records were recently implemented in outpatient clinics which staff were using. However, this was accompanied by increases in administrative time and difficulty in finding some records which did have an impact on timeliness of information access and potential for risks to patients. The trust had a plan to address staff concerns around this.
• Staff followed consent procedures and had a good understanding of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards which ensures that decisions are made in patients’ best interests.
• Children and young people were consented appropriately and correctly.

Are services caring?

• Across the hospital we found staff worked hard to ensure that patients were treated with dignity and respect, despite the challenges sometimes presented by the environment. However in medical and older people services, patients did not always receive care in a way that respected their privacy and dignity.
• Patients were asked for their views and response rates were high, with a high proportion of patients recommending care and treatment.
• Patients told us, and we observed, that staff were kind and compassionate, putting the patient at the centre of care.
• Patients, relatives and families were kept informed of plans for care and treatment. They told us they felt involved in the decision-making process and had been given clear information about treatment options.
• 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 live care, and counselling support where required.

Are services responsive?

• Bed occupancy in Royal Bournemouth Hospital range between 90-95%. This was consistently above the England average. 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.
• Performance in meeting national emergency access target for 95% of patients to be admitted, transferred or discharged within 4 hours varied through the year. The target was not met for 36 of the 52 weeks to March 2015. The trust had achieved the target (95.3%) July-September 2015.
• A lack of available beds in the hospital had resulted in delays in treatment for patients brought by ambulance and meant the emergency department was often full and this impacted on patient privacy.
• The number of ambulances waiting more than an hour to hand over patients had reduced significantly since the introduction of a rapid assessment and treatment area (BREATH) but still averaged four per month.
• There were long delays for patients with fractured hips to be transferred to Poole Hospital that treated trauma patients. The trust was taking action to introduce a formal pathway.
• The acute medical unit (AMU) and Treatment Investigation Unit (TIU) had been set up to manage the increasing pressures on beds due to an increasing demand.
• There were 55 medical outliers at the time of inspection. Their patients were appropriately assessed and followed by a team of medical consultant and junior doctors.
• The hospital performed above the England national average for the referral to treatment standards for patients to wait less than 18 weeks (May to July 2015). Previously, it had not met this standard on any of the 12 months to April 2015.
• Access to critical care beds within four hours was similar to comparable units. There were low rates of surgery cancellation due to lack of critical care beds. There was a higher than average number of delayed discharges, which resulted in mixed sex breaches, sometimes across several days. The service was performing better than similar services in avoiding out of hours discharges.
• The hospital’s cancellation rate for operations was below the England average for all quarters in 2014/15
• The trust was meeting national waiting times for diagnostic imaging within six weeks. However in October 2015 the percentage of patients Trust wide waiting over 6 weeks for all diagnostics was 6.2% compared to the England average of 2 – 2.5%. In diagnostic imaging no patients were waiting over 6 weeks in October 2015.
• Outpatients referral to treatment for patients was meeting the standard to wait less than 18 weeks. The trust short notice cancellation rate for appointments were lower (better) than the England average.
• Cancer waiting times for urgent referral appointments were below the national standard of two weeks (June 2014 – March 2015). However the trust was meeting the standard (April – June 2015). The trust was not meeting the standard for decision to treatment within 31 days (June 2014 – June 2015). The standard for 62-day cancer referral to treatment time was not met, specifically for urology and colorectal surgical treatments (June 2014 – June 2015). The trust was taking steps to reduce delays in these pathways.
• Most patients were seen by the hospital palliative care team within 24 hours. The rapid discharge service for discharge to a preferred place of care was responsive to the needs of patients and families.
• The hospital had implemented an improvement programme to reduce patient length of stay in hospital, and had identified specific barriers which they were addressing. There was a high number of delayed transfers of care. The main cause of delays was waiting for NHS non-acute care and patient and family choice, to meet patients’ ongoing needs. The provision of community services, especially care home and nursing home places, also caused delays.
• The environment did not always support patient needs. Women on the urogynaecology ward had to walk past male patient bays to access toilet facilities. Not all wards had been refurbished to improve the environment for patients living with dementia, but this was planned.
• Clinical staff knew how to access information to support them in meeting the needs of patients with a learning disability or living with dementia. They demonstrated an understanding of adjustments that could be made to support patients.
• There was a robust complaints handling process and responses to complaints were detailed and considerate. Staff understood how to manage complaints and there was evidence of learning from concerns and complaints. However, complaints were not being responded in a timely manner, in July 2015, only 50% of complaints were responded to within the trust target of 25 days.

Are services well-led ?

• The trust had published its vision, values, mission statement and objectives, and had taken action to assess and improve staff understanding of these. The trust had recently introduced values based appraisal and staff had better understanding of trust values if they had completed appraisal.
• The trust described its five-year strategic plan for patient care, underpinned by six strategic objectives, taking into account the two possible outcomes of the clinical services review. The wider strategic direction of services was largely contingent on the ongoing outcome of the Dorset wide clinical services review. Service leads agreed with the trust’s preferred option to become the major emergency hospital in the area.
• Most services had local strategic plans and were monitoring progress although this varied. The end of life care overarching strategy was produced in response the inspection, but had not been through consultation or approval by the board.
• Most services had had effective clinical governance arrangements to monitor quality, risk and performance. However, governance processes in urgent and emergency care , maternity and gynaecology were not always effective in identifying issues and making improvements to safety and quality
• Local risk registers did not always reflect all of the concerns described to us by staff, or provide sufficient detail on actions being taken. Information about risk and quality issues were not always shared with staff.
• Staff were positive about the local leadership and the trust management focus on improving the hospital’s culture. However many staff noted a lack of visibility of the senior executive team.
• Staff commented positively on local culture and teamwork. They said they would raise concerns about patient care if they witnessed poor practices.
• Patient feedback was mainly through survey feedback or FFT, but there were some patent focus groups and the hospital had worked the local Healthwatch to obtain patient views.
• Ideas to innovative and improve services were encouraged. There was participation in research and quality improvement projects
• There was a cost improvement transformation group for every directorate in the trust. The service leads considered ‘safety and quality’ as a priority in the cost improvement plans (CIPs).

We saw areas of outstanding practice including:

• The interventional radiology department had been awarded exemplar status by the British Society of Interventional Radiology for continuous audit, review and research in the unit, and improving patient experience. This award had been retained twice. The staff team were particularly proud of this achievement, particularly as they were not linked to a teaching hospital.
• In Maternity and Gynaecology the Sunshine team offered support to women that were assessed as being vulnerable. They could be vulnerable due to mental illness or learning disability, but also from alcohol and substance misuse. The team worked with the local centre that cared for women who had been trafficked to Britain. The Sunshine team worked across health and social care and had excellent relationships with the police, education and the mental health. The service had been recognised by an all-party parliamentary group for its work with vulnerable women.

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

Importantly, the trust must ensure :

• At all times, emergency department patients are assessed and treated according to nationally agreed standards, particularly those for sepsis and fractured neck of femur
• Emergency department transfer equipment is checked regularly to ensure that it is always ready for use.
• All incidents are reported using the trusts incident reporting process and staff receive feedback.
• Pain relief, drinks and food are given in a timely manner .
• All staff comply with good hand hygiene and infection control practices
• Equipment is appropriately labelled, maintained, checked, cleaned and tested.
• Equipment that poses a risk of cross contamination is disposed of promptly
• That all premises and environments used by patients are clean, secure and safe for use including theatres and the corridor between Derwent suite and main hospital.
• All emergency equipment is checked and maintained in working order
• All medicines are stored securely, correctly and within a safe temperature range .
• Patient medicines are checked and recorded to ensure they receive the correct medicines when admitted to hospital
• Medicines are administered in a safe manner, following national guidance and trust procedures
• Patient risks are assessed and documented in a timely manner and escalated appropriately
• A policy, protocol and appropriate equipment is available to remove a collapsed woman from a birthing pool, and staff are trained in its use.
• Sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed at all times. Including sufficient numbers of permanent staff to provide guidance to the temporary staff about meeting patient individual needs in a safe manner.
• Staff receive appraisal annually in line with trust policy and procedures and access to clinical supervision improves .
• Privacy and dignity of patents is protected during care and treatment.
• The hospital escalation procedures are improved so that delays to ambulance patients are minimised
• Delays in discharge are reviewed to prevent patient stay in an inappropriate location and mixed sex breaches, particularly in critical care services.
• There are effective systems to identify, assess, monitor and improve the quality and safety and mitigate risks across departments, in particular maternity and gynaecology services and the emergency department

The trust should

• Continue to develop inclusive leadership style and an open and transparent, and patient focused culture.
• Ensure governance arrangements are formally evaluated and action is taken around areas of risk and effectiveness.
• Improve relationships with its council of governors
• Further develop patient and public engagement
• Ensure all staff feel appropriately engaged with strategic and operational plans are able to raise concerns effectively.
• Continue to work effectively with partners particularly around systems resilience

Professor Sir Mike Richards

Chief Inspector of Hospitals