A star

Norfolk and Norwich University Hospitals NHS Foundation Trust

Evidence appendix Colney Lane Date of inspection visit: Colney 22 January to 27 February 2019 Norwich Norfolk Date of publication: NR4 7UY 15 May 2019

Tel: 01603 286286 www.nnuh.nhs.uk

This evidence appendix provides the supporting evidence that enabled us to come to our judgements of the quality of service provided by this trust. It is based on a combination of information provided to us by the trust, nationally available data, what we found when we inspected, and information given to us from patients, the public and other organisations. For a summary of our inspection findings, see the inspection report for this trust. Facts and data about this trust

The Norfolk and Norwich University Hospitals NHS Foundation trust consists of the Norfolk and Norwich University Hospital (NNUH) and Cromer and District Hospital, with some services available at other sites across Norwich. The status of foundation trust was achieved in May 2008. The trust is one of the largest teaching hospitals in the country and provides a full range of acute clinical services including more specialist services such as oncology and radiotherapy, neonatology, orthopaedics, plastic surgery, ophthalmology, rheumatology, paediatric medicine and surgery.

The Norfolk and Norwich University Hospital (NNUH) is a 1,100-bed teaching hospital with state- of-the-art facilities for modern patient care. It has 998 adult and child inpatient beds across 31 inpatient wards, 154 day case beds, 90 maternity beds and 29 operating theatres (including one Vanguard theatre). The hospital was built in 2001 and is based on the Norwich Research Park. The NNUH provides care for a tertiary catchment area of approximately 1,016,000 people from Norfolk and neighbouring counties across the STP. The trust works closely with the University of East Anglia’s Faculty of Medicine and Health Sciences to train health professionals and undertake clinical research.

Cromer and District Hospital is located on the north Norfolk coast and the hospital was redeveloped in a £15 million scheme, opening in March 2012. It has a Minor Injuries Unit and provides a range of outpatient and day-case services.

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The trust carries out nearly one million outpatient appointments, day case procedures and inpatient admissions annually.

The population served is predominantly the people of Norfolk and north Suffolk, although some patients are referred from further afield in particular to access specialist services available at the trust.

(Source: Trust Website/ Routine Provider Information Request- Context Acute)

Acute hospital sites at the trust

A list of the acute hospitals at Norfolk and Norwich University Hospitals NHS Foundation Trust is below.

Details of any Name of acute Geographical area Address specialist services hospital site served provided at the site All CQC acute core services. There is also a dedicated children’s hospital (the Jenny Lind Children’s Hospital) within the hospital. The NNUH provides care for a tertiary Norfolk and Norwich Norfolk and The trust also provides a catchment area of University Hospital, Norwich range of more specialist approximately Colney Lane, University services such as cancer 1,016,000 people from Norwich, Hospital care and radiotherapy, Norfolk and NR4 7UY orthopaedics, plastic neighbouring counties surgery, ophthalmology, across the STP. rheumatology, children’s medicine and surgery, and specialist care for sick and premature babies. The hospital has a minor The hospital is based Cromer Hospital, injuries unit and also in Cromer on the North Cromer and Mill Road, provides a range of Norfolk coast and District Hospital Cromer, outpatient and day-case serves the North NR27 0BQ services. Norfolk population.

(Source: Trust Website/ Routine Provider Information Request- Context Acute)

Is this organisation well-led?

Leadership There had been some significant changes in the executive leadership team. We found that there was a stronger clinical voice and a more cohesive approach from operational and clinical perspectives. However, there continued to be inconsistencies in leadership across the divisions. Not all managers at all levels in the trust had the right skills and abilities to run a service.

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At the time of inspection, in February 2019, a complete executive team remained in place. Five of the six executive directors were substantive posts. The chief operating officer (COO) post was interim with recruitment planned for the substantive appointment. The board of directors consisted of six executive directors and seven non-executive directors (NEDs). The Chief Executive Officer (CEO) had been appointed as interim CEO for the trust in August 2015 and had become substantive in November 2015. The chair had been in post since May 2013. There had been several changes in members of the executive team, in the twelve months prior to this inspection, with new appointments of the chief nurse, medical director, chief financial officer and chief operating officer. We found that the chief nurse and chief financial officer both had a wealth of previous experience which meant they had knowledge and skills required to undertake these positions. Both the medical director and the interim chief operating officer were internal appointments, having previously been deputy medical director and divisional operations director respectively. This meant they had previous knowledge of the trust and both were well known to staff. The medical director maintained their clinical commitments. At our previous inspection, published June 2018, we had reported a disparity in the leadership and line management processes for members of the executive team. The executive team was not functioning effectively or cohesively and there was an unproportionate operational focus. We issued three requirement notices (RN) and told the trust it must improve. The RN related to functionality of the board, support for directors, inconsistent processes in recruitment, including steps taken to ensure directors were fit and proper, line management at executive level and oversight and scrutiny by the chair and non-executive directors (NEDs). At this inspection, we found that actions had been taken in respect of these requirements. New appointments had positively impacted the dynamics of the team and the way in which the leaders at executive level functioned. The individual changes in members of the executive team had removed the previous perception of an inner circle and had improved communication amongst the executive directors. The chief nurse and medical director worked well together and had strengthened the clinical voice at board level and clinical concerns were now prominent. The triumvirate working between the chief nurse, medical director and interim chief operating officer appeared to be working well which was a significant improvement. There was a unified approach and we saw a level of healthy, constructive challenge that had improved the balance between operational and clinical leadership and focus. Whilst these changes in appointments had brought improvement and a stability to the board this remained in its early stages. There was a risk to the sustainability of this as further changes at executive board level were due to take place throughout 2019. We were informed that the chair would be retiring in the spring of 2019 when his tenure was complete. The CEO had also taken the decision to leave the trust in the autumn of 2019. The director of workforce had resigned and would be leaving the trust by the summer of 2019 alongside three NEDs, that had also reached the end of their tenure. Succession planning had commenced at the time of our inspection. The initial focus was on the recruitment for the chair and NEDs with chair interview dates scheduled. The director of workforce stated that the process had also meant the opportunity to reaffirm the governors’ responsibilities and status as they appoint the chair. The CEO explained that the early announcement of their intention to leave had been intended to allow the new chair, once appointed, to participate in the recruitment and appointment of the new CEO.

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Whilst there were no immediate concerns around technical capabilities of the executive board there was recognition that experience levels varied amongst individuals. For this reason, the board development programme that had started during the last inspection continued. The interviews that were undertaken with each of the executive team confirmed that they all recognised this as important, especially with future changes of the team to come. We reviewed the “board development and strategy development programme 2019/20” report to the trust board, dated 22 February 2019. We noted that this report referenced the risks and challenges associated with the significant turnover in the board membership. It was recorded that at a time of heightened operational, financial and regulatory pressure came an increased importance of giving adequate focus to nurturing the function of the board. Board development actions from the last reporting period and next month were included in this report to document progress and enable board oversight. We reviewed the board development plan itself, dated December 2018, that outlined actions taken following our previous report published in June 2018. The plan was developed by a working group of the board and was discussed and agreed at the board meeting on 21 December 2018. The trust board had commissioned an independent review of board capacity, capability and effectiveness. The report was received on 29 November 2018 and recognised that ongoing development would be required to ensure the board was adequately equipped to lead the trust through improvement and complex change across the local system. Seven themes were detailed including time for whole board learning and thinking, executive team portfolios and board capacity. These themes were included in the development programme itself and aligned with our previous inspection findings. The plan summarised actions that were already taken in 2018/19. Ongoing plans were outlined in a “Board Development Plan on a page”. We noted that there were aspects that related to the whole board, executive and non-executive directors (NEDs) and individual development. As well as foundation aspects such as vison, values, culture and behaviours, strategy and development planning, well led framework and governance structures and reporting. Summary of actions taken for board development in 2018/19 were included and fell under five topics; knowledge and skills acquisition, strategy development, ward to board, collective working and team development. Knowledge and skills acquisition topics included infection prevention and control and safeguarding. The safeguarding lead during interview confirmed that training to the executive team had just taken place in February 2019, as outlined in the plan. There was a clearly outlined framework of scheduled events for the board, management board and senior management team spanning from February 2019 to February 2020. This included board strategy and development sessions, monthly clinical visibility and assurance visits prior to both board and management board meetings, four identified management board strategy and development away mornings, quarterly executive team away sessions, quarterly board dinners and the board annual self-assessment, which was scheduled for April 2019. Topics for ongoing board development included, but were not limited to, the quality improvement strategy, capacity and winter planning, estates masterplan and research strategy. Feedback from NHS Improvement (NHSI) use of resources inspection stated that there appeared to be a lack of strength and depth in commercial / business partnering, and strategic finance skills. We saw that a there had been a development session in relation to capital and investments and the medium term financial strategy in October 2018. Operational and financial planning 2020/21 was scheduled for February 2020.

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All executive directors we interviewed confirmed that the allocated mornings and away days had taken place as scheduled and that these had been beneficial. In addition, the CEO encouraged coaching, buddying, and external visits to learn from other organisations. The interim COO told us that they had attended an NHSI induction and had joined a COO network. The Monday afternoon executive team meeting, which was not minuted, continued to be used as an opportunity for the team to discuss forthcoming items prior to the hospital management board meetings, and was felt supportive by the recently appointed directors. There were no scheduled one to one sessions for the executive directors however they confirmed with us that this would be accommodated if needed. Regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 states that providers must take proper steps to ensure that their directors, or equivalent, are fit and proper for the role (FPPR). It applies to a provider’s board directors, board members and equivalents, who are responsible and accountable for delivering care, including associate directors and any other individuals who are members of the board, irrespective of their voting rights. We reviewed six personnel files of executive directors, including those most recently appointed, and three NED files. We found that there had been improvements made in the process for FPPR, recruitment and line management of the executive team and that previous inconsistencies had reduced. Most files were complete with records of the recruitment process, interview notes, reference checks, disclosure and barring service (DBS) check, employment history and FPPR checklist. All six files detailed an annual appraisal with current objectives outlined.

We found that in the three NED files reviewed there remained some inconsistencies. In one there was no documented checks of professional qualifications, where this would be applicable, only one written reference with an additional documented note of a second verbal reference. In the second there were no references recorded, with “N/A” noted on the tick list, no check of professional registration and no interview notes and in the third no references. Only one of the three files had appraisal documentation although the other two had an email from the chair confirming appraisal but no documentation. However, we recognise that these directors had been in place for at least two years. There was a ratified FPPR policy in place, version 2 dated October 2017, which was next due for review in October 2019. The policy referred to existing staff under point 5.2 and stipulated annual checks were required in relation to self declaration, insolvency and bankruptcy checks and annual appraisal. All three records reviewed had these undertaken within the last 12 months and therefore were in line with policy.

The divisional management structure had been introduced in April 2016 and decision making had begun to be devolved down to divisional level at our previous inspection. Each division was led by a triumvirate of clinical leaders; a chief of division, divisional operations director and divisional nursing director. At that time, we had found that leadership within the divisions was variable, independent working and limited evidence of cross division working. Information provided by the trust prior to this inspection stated that there had been investment in strengthening nurse leadership, as part of the divisional triumvirates. However, we found that inconsistencies remained amongst the effectiveness of the leadership within the divisions. The level of support and oversight provided varied depending on core service. We provided feedback to the executive team during, and following, the core service inspections on 22 and 23 January 2019 and the unannounced inspection of the emergency department (ED) on 14 February 2019. We found that there were systemic failings in the risk management of patients within the ED. We outlined an embedded negative culture, with disillusioned staff, ineffective

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 5 management and leaders without the appropriate levels of training development and support to enable them to lead effectively. There was recognition amongst the executive team that the urgent and emergency service was an identified risk and was an area of focus. We were informed by the chief nurse that there was an organisational strategy for the team and that support and development would be undertaken with the clinical leaders to improve their skills in team management, leadership and approachability. The visibility of leaders at senior levels had improved. The clinical divisional teams remained very visible and staff found them approachable. The executive team had taken steps to improve their visibility through a variety of forums. Board to ward clinical and departmental visits had been introduced prior to board meetings that involved both executive directors and NEDs. Overwhelmingly the directors stated these had been beneficial and helped focus meetings from patient and staff perspectives. As a result, these had been introduced before management board meetings as well as executive board meetings. We reviewed the board minutes from September 2018 to January 2019. We saw that reflections on development and assurance visits were recorded. Non-executive directors described the last inspection findings, published in June 2018, as a wakeup call. They had been aware that there was an historic problem of bullying within the organisation but had believed that this was improving. They had been shocked at the high number of whistle-blowers contacting CQC which had evidenced that the trust had further work to do. In part they believed that entering special measures had been the catalyst for change. There was recognition that escalation processes needed to improve. A people and culture committee had been introduced, and two meetings held at the time of inspection, which they hoped would have a positive impact.

The previous chief pharmacist had retired in November 2018. Their replacement was internally recruited which meant that there had been a planned handover. The new chief pharmacist had support from the new chief of division for operational matters but had received no personal support or one to one meeting since commencing their new role. Some areas across the trust were getting additional pharmacy support, including surgery, emergency department and diabetes, and there was an increased pharmacy service at weekends. However, other areas including critical care and the outpatients parenteral antimicrobial therapy (OPAT) service were not fully supported due to a high vacancy rate in the pharmacy department.

Board Members

Of the executive board members at the trust, none were from Black Minority Ethnic (BME) communities and 33.3% were female. Of the non-executive board members, none were from BME communities and 42.9% were female.

Staff group BME % Female % Executive directors 0.0% 33.3% Non-executive directors 0.0% 42.9% All board members 0.0% 38.5%

(Source: Routine Provider Information Request (RPIR) – Board Diversity tab)

None of the recently appointed members of the executive board were from BME communities.

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The director of workforce informed us that the trust recognised this and that future recruitment may provide further opportunity to address this. Vision and strategy The trust had a clear vision, set of values and corporate strategy with quality and sustainability as the top priorities. Staff knew the trust corporate vision, values and strategy. However, local individual service strategies varied in stage and development with inconsistencies found in the clarity of direction from divisions. The trust vision, values and objectives remained unchanged from our last inspection. The trust vision is “To provide every patient with the care we want for those we love the most”. Five values underpinned this vision; people focused, respect, integrity, dedication and excellence. The trust corporate strategy was agreed originally in 2016, updated in 2017 and was reviewed annually by the trust board. It had four clear objectives supported by several priorities which had been translated into a portfolio of projects.

The four objectives to the strategy were: 1) We will be a provider of high quality health and care services to our local population; 2) We will be the centre for complex and specialist medicine for Norfolk and the Anglia region; 3) We will be a centre of excellence for research, education and innovation 4) We will be a leader in redesign and delivery of health and social care services in Norfolk.

The vision, values and strategy had been developed using a structured planning process. There had been a widespread consultation exercise within the trust and with external stakeholders. Information provided stated that online surveys and face to face interviews had been the primary means of consultation and that the governors had been closely involved in the development of the original strategy. We found during the core service inspections, on 22 and 23 January 2019, that staff knew the trust corporate vision, values and strategy. However, there were inconsistencies across the services in relation to local strategy and clear direction from divisions.

Information provided prior to the inspection, and confirmed through executive interviews, outlined that a key focus of the corporate strategy was developing additional capacity to cope with the continued increasing patient demand facing the trust. The trusts senior team had a good understanding of the needs of its local population and the provision of services of other healthcare providers. Therefore, the corporate strategy had been developed to take these into account and align to the wider health and social care economy. It set out how the trust would collaborate and contribute to the redesigning of healthcare across the Norfolk and Waveney Sustainability and Transformation Plan (STP). The trust had senior representation on the STP and worked well with other stakeholders to develop services. Work was underway towards the trust taking a role as lead provider based on the Attain Norfolk-wide lead provider model of collaboration. Initially this would see the trust provide clinical support across a range of services to one of the other two acute trusts in Norfolk. The Eastern Pathology Alliance is a joint venture between all three acute trusts in Norfolk. The Norfolk and Norwich hospital is the network host laboratory.

Progress towards delivery of the corporate strategy and the review of performance against key priorities was monitored by the board every six months. Trust information referenced that there had been some exceptional circumstances which had impacted on delivery of the strategy that included financial special measures, general restrictions around NHS investment spending and CQC Special Measures, however the board felt that the trust was still making good progress. We reviewed board agendas, board meeting minutes, board papers and a range of trust documents

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 7 including the cost improvement programme (CIP) and board assurance framework (BAF). All of which referenced the strategic objectives which meant these were reflected during board meetings.

To focus on the proprieties for achieving and developing good quality, sustainable care a five-year quality and safety improvement strategy was being crafted through a series of staff engagement events. This was presented at the January 2019 Trust board for discussion

At the time of inspection, a medium term financial strategy was not in place but was in development. The trust faces significant risks due to a lack of available capital finance, and the trust’s draft strategy was contingent on external support to achieve a breakeven position in the medium term. The trust board away day on 26 October 2018 included demand, capacity and estate development and the medium term financial strategy.

A workforce strategy for pharmacy was in place that ensured a planned handover on the retirement of the previous chief pharmacist in November 2018. There was a 25% vacancy rate for both pharmacists and technicians. Plans included recruitment and discussion with other local organisations about shared rotational posts. A medicines optimisation strategy was in place covering 2017 to 2020 Culture A positive culture that supported and valued staff, and created a sense of common purpose based on shared values was not embedded across the trust. Managers across the trust recognised the importance of culture change and had begun focused actions however there remained areas of inconsistency. At our previous inspection, published June 2018, we had reported a lack of clinical staff empowerment, divide between operational and clinical teams, a sustained bullying culture and fear of reprisal amongst staff if they should raise concerns. We issued a requirement notice (RN) and told the trust it must improve. The RN related to the whistleblowing process and improvement of culture, openness and transparency throughout the organisation. At this inspection we found that actions had been taken, with some improvements evident, however this was inconsistent as pockets of poor culture remained in certain areas. In the intervening period between CQC inspections the trust had taken a variety of actions to address whistleblowing and the concerns we raised. These included: 1. Revision of the escalation policy to include specified actions and support provision at times of severe operational pressure. 2. Commissioning of King's Fund diagnostic review to get staff's input into organisational development and cultural development plans. The King’s Fund is an independent charity working to improve health and care in England. 3. Implementation of a quality improvement plan (QIP) that included specific actions to respond to concerns identified by CQC as a result of direct staff contacts. An example of this was a review of ward configuration in the Surgery division in response to feedback from staff. 4. Leading with PRIDE. This was a programme of management masterclasses to equip managers to build the right culture. This took place in September 2018 and involved 650 managers and leaders from across the trust. 5. Communicating with PRIDE. This was a framework to improve communication between individuals and teams that upholds the organisational values. Communicating with PRIDE was launched in November 2018.

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We received nine whistle blowing contacts between our core service and well led inspections (between 22 January and 25 February 2019). Themes were varied and included, but were not limited to, inconsistent management styles with some leaders perceived as overbearing and dictatorial, behaviours of individual employees and lack of involvement and engagement. This was a significant drop in whistle-blowers raising concerns directly with us in comparison to the number we received during our previous inspection, which indicated that the actions taken were beginning to have some positive impact. Findings from the core service inspections in January 2019, indicated that, in the majority of areas, staff now felt able to raise concerns. Results in the 2018 staff survey in response to the question Q8g, “my immediate manager values my work” had increased from 67% in 2017 to 69.3%. However, this was not consistent or embedded across all areas. The Kings Fund report confirmed similar areas for improvement as those we had highlighted. Findings included some disconnect between board and ward, particularly with patients, clinical and other frontline staff. Considerable variation between divisions. Some staff experienced ‘dictatorial’, top-down commands, a lack of involvement, instances of blame, dismissiveness, negativity and poor communication. They also reaffirmed a legacy of inadequate training and development for managers. We reviewed the trust action plan in response to the Kings Fund review and found that actions, timeframes and leads had been identified for all 15 points. Point four related to systematic development programmes for middle leaders including a process of 360 appraisals, development assessment and personal development planning which would be tailored and delivered to clinical and managerial leaders across the organisation, commenced from September 2018. There remained pockets of poor behaviour and culture. It had been identified by the executive team that the pockets of poor culture fell within areas of increased pressure, such as the emergency department, acute medicine, anaesthetics and histopathology. There was recognition that there would need to be a long term concerted effort, with multiple areas of focus before any sustainable change would be achieved. The emergency department was one area of increased concern where an impact was seen on patient safety. Despite verbal acknowledgment from the executive directors that access and flow was an organisational responsibility this was not evident in practice and staff within the ED department still felt blamed for capacity pressures. Despite the newly refurbished environment, and additional capacity rapid assessment area, leadership strength varied depending on which lead clinicians were in charge and processes were not implemented. In addition, flow was not managed throughout the trust and clinicians on the wards did not take ownership that they contributed to this. We found behavioural issues across staff of all grades within the emergency department. This was not bullying but more a lack of respect and civility when communicating to each other. This had become a learnt behaviour, with a level of acceptance, as this had been normalised. During our unannounced inspection on 14 February 2019 all staff we spoke with, without prompting, told us about the way in which they were treated, the fear they had at speaking out, how unhappy they were, how they were not involved in decisions made and that their passion for providing great quality care was compromised by the decisions leaders made. We raised these concerns on site and the trust acted to immediately respond. There were a number of appropriate actions outlined that included organisational development and working groups to get staff involved and engaged. The chief executive officer (CEO) was aware that the results of the 2018 survey had evidenced that poor culture had not been eradicated. The board were aware of the “hotspot” areas and those where it was evident that there was real positivity and good teamwork. The CEO stated that

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 9 there would be an analytical look at those positive areas where staff felt empowered, motivated and involved to identify key differences and then replicate in those less engaged areas.

The staff survey identified areas for improvement in direct relation to morale and the impact this had on retention of staff. Whilst the overall result showed that the trust was in line with similar acute trusts with a score of 6.0 against an average of 6.1, it scored worse than the average for similar acute hospitals in all nine of the detailed information questions relating to this theme. There had been a steep decline in Q4c “I am involved in deciding on changes introduced that affect my work area / team / department” which had reduced from 54.3% in 2014 to 48.2% in 2018. Q6b “I have a choice in deciding how to do my work” scored 51.2%. Q6c “relationships at work are strained” scored 40.1%. Q23 a, b and c related to staff considering leaving the organisation and when. 31.1% of staff had thought about leaving, 18.3% in the next 12 months and 13.5% would leave as soon as possible. The trust was closest to “worst” in response to Q7c “I am able to deliver the care I aspire to” scoring 61.6% and the worst being 58%.

The director of workforce told us that they had included a briefing around the staff survey results to the board meeting on 22 February 2019. We also noted that risk relating to culture was included in the board assurance framework (BAF).” Threat1.6 Potential deficit in staff motivation, engagement & resilience may impact on quality of care”, which meant the board were sighted on this concern.

The trust had put in place several structures to enable staff to report concerns. Previously we had reported that the freedom to speak up (FTSU) guardians were under resourced in time and development. This had been echoed by the Kings Fund report. A people and culture committee had been introduced and had met twice at the time of our inspection. A report was presented at the 28 September 2018 board meeting in relation to the Freedom to Speak Up self-review tool. The report outlined that a crucial step to further promoting a speak up culture was to establish and recruit a full-time, lead Freedom to Speak Up Guardian (FTSU). This had taken place and they were due to start in post on 18 March 2019. The CEO had continued to undertake “Viewpoint”, a monthly all staff meeting and still held “tea with Mark” sessions, although less frequently. In addition, they had introduced a “chat with the chief” which was a monthly drop-in opportunity for staff to discuss any subject. They told us that these sessions were beginning to have traction and gave an example of one recent concern that related to poor behaviours not in line with the PRIDE values. This related to staff in the travel office receiving abusive communication around car parking. With the permission of the individual the CEO raised this at Viewpoint the following month, as an opportunity to remind staff of the trust values and how they should treat each other. In response to “Call to Action – Tackling Bullying in the NHS” the trust had initiated several actions including Leading with PRIDE and Communication with PRIDE workshops. Call to Action is a key initiative of the Social Partnership Forum, a national body, whose members include the Trade Unions and NHS Employers. The trust held a bullying event in August 2018 and had replaced the dignity at work policy with a dignity at work framework that was available on the staff intranet. We reviewed the framework, dated October 2018, and saw that it outlined clearly the statement of intent to tackle bullying. The framework placed the emphasis on informal resolution where possible and detailed a number of resources and quick guides available to staff. The Guardian of Safe Working Hours (GoSWH) is a senior appointment, that was introduced alongside the new junior doctor’s contract in 2016/2017. All organisations employing or hosting 10

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 10 or more doctors in training are required to appoint a GoSWH. They are independent of trust management and champion adherence to safe working hours, oversee safety-related exception reports and monitor compliance with the system. The GoSWH at the trust was proactive in their engagement with all grades of medical staff and was committed to ensuring work schedules promoted appropriate, safe medical staffing whilst safeguarding the working hours of doctors in training. Exception reporting was open to all doctors. They analysed the reports to look for trends and undertook independent surveys for triangulation. There was a quarterly junior doctors’ forum in place, that was well attended, and we saw evidence that several actions had been taken to address concerns raised, such as rota redesign, lazy boy recliners in certain rooms to provide private areas for rest and room availability if staff were too tired to drive home. A junior doctor ‘WhatsApp’ could be used to raise a concern or staff could contact the guardian directly. Reports from the GoSWH were presented to the workforce committee and hospital management board. We saw that the British Medical Association (BMA) had provided positive feedback about the engagement that the GoSWH had achieved. There was no patient representative on the medicines safety committee, and no process within the trust to identify a patient representative. The chief pharmacist had tried to seek a representative for a research project, however the trust had not been able to help and they told us that they were having to look at other options.

Staff Diversity

As of March 2018, Norfolk and Norwich University Hospital NHS Foundation Trust employed 7,870 people, of which 80.1% are women.

(Source: Annual Report and Accounts 2017-18)

The trust provided the following breakdowns of medical and dental and nursing and midwifery staff by Ethnic group.

Ethnic group

Staff group White (%) BME (%) Not stated (%)

Public Health and Community Health Services 33.3% 66.7% 0.0% Medical & Dental staff - Hospital 56.3% 38.0% 5.7% Qualified Nursing and Health Visiting Staff 83.2% 12.9% 3.9% Qualified Healthcare Scientists 87.6% 9.5% 2.9% Other Qualified Scientific, Therapeutic & Technical staff 87.8% 9.0% 3.2% Support to doctors and nursing staff 91.8% 4.9% 3.3% Qualified Allied Health Professionals 92.0% 4.5% 3.5% NHS infrastructure support 93.0% 4.4% 2.7% Qualified nursing midwifery staff 92.9% 3.9% 3.1% Support to Scientific, Therapeutic and Technical Staff 94.6% 3.3% 2.1% Qualified ambulance service staff 100.0% 0.0% 0.0% Other Non-Medical staff 100.0% 0.0% 0.0%

(Source: Routine Provider Information Request (RPIR) – Diversity tab)

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We were not assured that equality inclusion and diversity was fully embedded at the time of our inspection. The trust strategy did not explicitly include workforce race equality, which was acknowledged by the trust in the information provided. We reviewed the equality, diversity and inclusion (EDI) overview document that set out overarching EDI objectives and goals in line with legislative requirements. This document was not version controlled and was last updated for hospital management board on 7 November 2017.

We reviewed the “equality, diversity and inclusion workforce focused action plan” and saw that this had been updated in August 2018 but that progress remained slow. Each action identified a lead with responsibility, date for next review, details of actions taken and was referenced to specific workforce race equality standard (WRES) indicators. Only two of the twenty actions had been completed, the remaining 18 actions had been updated as to progress but subsequent review dates had not been assigned. For example, action seven was to develop a recruitment web page that promoted the trust as an inclusive employer of choice. The update on 19 July 2018 stated that work was being undertaken with an external agency to develop a bespoke web page and that mock ups were available. We could not find any evidence of this bespoke page on the trust website and found there was limited reference to equality and diversity overall. Searching for equality and diversity brought eight results spanning back to 2008. The most recent being the publication of “The Care Certificate Workbook Standard 4 Equality and Diversity” which was in October 2018. However, we saw that the video on the “working for us” page included a diverse selection of staff, referred to nurses from other countries and that Norwich is LGBT friendly.

Information provided by the trust identified that there was a dedicated email address in relation to equality and diversity that staff could use to contact and raise issues. Two new staff networks had been established since our previous inspection. These were the Black, Asian and Minority Ethnic (BAME) network and the Lesbian, Gay, Bisexual, Transgender, Queer or Questioning (LGBTQ) network. The first meeting of the LGBTQ was held in November 2018. We were not provided with details of any future dates or details if BAME had met at the time of inspection.

Results from the 2018 staff survey in relation to the equality, diversity and inclusion theme detailed an improvement in two of the four questions and a decline in two as follows: • Q15a “In the last 12 months have you personally experienced discrimination at work from patients / service users, their relatives or other members of the public?” This score had been slowly decreasing, therefore showing improvement, over the last three years with scores of 5.5% in 2016, 5.3% in 2017 and 5.2% in 2018. This was better than the average for similar acute trusts (6.1%). • Q15b “In the last 12 months have you personally experienced discrimination at work from manager / team leader or other colleagues?” Again, this score had seen an improvement, in the last 12 months with a score of 8.5% in 2017 reducing to 8.2% in 2018. However, remained above the average, worse than, similar acute trusts (7.7%). • Q14” Does your organisation act fairly with regard to career progression / promotion, regardless of ethnic background, gender, religion, sexual orientation, disability or age?” This score had declined from 87.2% in 2017 to 86.9% in 2018, however this remained above the average, better than, similar acute trusts (83.9%). • Q28b “Has your employer made adequate adjustment(s) to enable you to carry out your work?” This score had declined from 80.2% in 2017 to 76.5% in 2018, however this remained above the average, better than, similar acute trusts (72%).

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NHS Staff Survey 2018 results – Summary scores

The following illustration shows how this provider compares with other similar providers on ten key themes from the survey. Possible scores range from one to ten – a higher score indicates a better result.

The trust’s 2018 scores for the following themes were significantly lower (worse) when compared to the 2017 survey: • Health and wellbeing • Quality of care (Source: NHS Staff Survey 2018)

The 2018 format of the NHS staff survey had changed from the previous year. There were 3,517 completed questionnaires, which meant a response rate of 46% against an average acute trust response rate of 44%. In the new format key findings have been replaced by identified results across ten themes; equality, diversity and inclusion, health and wellbeing, immediate managers, morale, quality of appraisals, quality of care, safe environment (bullying and harassment), safe environment (violence), safety culture and staff engagement. The trust scored the same as the average for similar acute trusts in two of the ten themes; equality, diversity and inclusion and quality of appraisals. They scored just better than average in two; health and wellbeing and safe environment (violence) and scored just worse than average for the remaining six, with the scores being within 0.3 of a difference. We noted that the trust overview score for each theme was either marginally above or below the average score for 20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 13

similar trusts meaning that there were no areas where they were either distinctly higher or lower in comparison. A key feature of the new format is that the survey reports provide organisations with up to five years of trend data across theme and question results, as well as then providing detailed information. Trend data provides a much more reliable indication of whether the most recent results represent a change from the normal for an organisation than comparing the most recent results to those from the previous year. The trust staff survey results identified that nine of the ten themes had remained relatively static over the four years however there had been improvement in relation to quality of appraisals with the score increasing from 4.4 in 2015 to 5.4 in 2018. The detailed information section of the survey contained the questions contributing to each theme, grouped together. Question results are also benchmarked so that organisations can make comparisons to their peers on specific areas of staff experience. Question results provide organisations with more granular data that will help them to identify particular areas of concern. The director of workforce told us that the new format was beneficial as it provided visibility to staff of the trust performance over time. They stated they were particularly pleased with the increased response to Q21a, 21c and 21d that related to staff engagement and recommending the organisation as a place to work / receive treatment. Although two remained just below the average for similar acute trusts all three had improved over the four-year period. However, Q21d “If a friend or relative needed treatment I would be happy with the standard of care provided” had dropped in the last 12 months from 76.2% in 2017 to 75.7% in 2018. The director of workforce stated that there had been a conscious decision from the executive board to report the staff survey findings in a more autonomous way by informing staff where the results could be found should they wish to review these. This was a shift from previous years when communication had been delivered with results, what the conclusions were and what actions needed to be taken. (Source: 2018 NHS Staff Survey)

Friends and Family test

The Friends and Family Test was launched in April 2013. It asks people who use services whether they would recommend the services they have used, giving the opportunity to feedback on their experiences of care and treatment.

The trust scored about the same as the England average for recommending the trust as a place to receive care from December 2017 to November 2018.

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(Source: Friends and Family Test)

Sickness absence rates

The trust’s sickness absence levels from October 2017 to September 2018 followed a similar trend to the England average. The trust’s sickness absence rates were lower than the England average from May to August 2018 but were similar to the England average in September 2018.

(Source: NHS Digital)

General Medical Council – National Training Scheme Survey

In the 2018 General Medical Council Survey the trust performed the same as expected for all 13 survey indicators. (Source: General Medical Council National Training Scheme Survey)

Governance The trust had effective governance structures, systems and processes in place to support the delivery of its strategy including sub-board committees, divisional committees and team meetings. We found that improvements had been made to refocus quality of care as a

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 15 priority. However not all divisions had matured at the same pace and more needed to be done to strengthen staff and patient voice at board. There was an established board of directors and management board reporting and accountability structure in place, which meant that information and reporting lines were clear from ward to board. Twelve committees / sub boards fed into the hospital management board (HMB). These included, but were not limited to, procurement board, risk and oversight committee, children’s board and financial improvement and productivity. Included in these were boards at a divisional level that fed into the divisional performance committee which then fed to HMB. The divisional model enabled devolved decision making, engaged clinicians and moved the trust towards becoming a clinically led organisation. Governance sub boards included clinical, safety and effectiveness, non-clinical safety, caring and patient experience and workforce and education. There was a cancer board, research oversight board, mental health board and clinical information management and technology committee. The divisions had been introduced in April 2016 and were beginning to mature although some were further developed than others. Divisional leaders and managers reported varying experience and comfort with the divisional structures when they were introduced. They also varied in their own confidence and capability to deliver within the divisional performance management structures. This meant that not all divisions had the same traction to move things forward. This may have been due, in part, to some senior staff having experienced a lack of empowerment from previous executive teams. There remained an element of having to seek permission before acting. For example, a pilot for fast track caudal compression, which had shown positive results within eight weeks, had gone to the chief nurse for approval rather than the decision being made at a local level. The new triumvirate of chief nurse, medical director and interim COO were working to change this and held regular meetings with the divisional leads. They informed us that they thought it was beginning to change and that the divisions were gaining strength. However, this had been slow to evolve considering that the divisions had been in place for almost three years at the time of inspection. The chief nurse and medical director had refocused quality of care as a priority. This was being brought together through the quality programme board (QPB), quality and safety committee, quality account and five-year strategy to ensure quality becomes embedded across the organisation. We reviewed the board meeting minutes, between September 2018 and January 2019. The terms of reference for the QPB were agreed and approved at the board on 28 September 2018. The quality and safety committee had previously been quarterly. This had been changed to monthly shortly after the arrival of the chief nurse, as it was recognised that quarterly did not enable timely response to patient safety and quality concerns. Divisional nurse directors (DNDs) and chiefs of division (CoDs) were included in the quality and safety committee and quality programme board. This had meant an improved level of discussion, ownership and responsibility from the divisional leads. This was also reaffirmed through the deep dive work as part of the trust oversight assurance group. An accountability framework was to be introduced to strengthen this further. The trust committee structure and content of associated papers had been reviewed by the chief nurse and medical director shortly after their appointments. The clinical governance agenda, minutes and action log templates had been revised and standardised for consistency as a result. These were agreed at departmental and divisional level. Ward level dashboards and monthly performance meetings were established. This meant that patient safety and clinical governance 20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 16 were now emphasised priorities for divisional reporting at monthly executive performance meetings. It was recognised that support and development for divisional leads, NEDs and governors had previously been lacking. We had reported in June 2018, that there had been limited cross divisional working and oversight, scrutiny and challenge from the chair and NEDs. We found that executive and NED walkabouts and specific directorate walkabouts by the quality and safety committee had been introduced. The DNDs were undertaking cross directorate projects. The monthly quality programme board was chaired by the CEO and had NED representation. The trust safeguarding lead told us that they had highlighted to the board on 22 February 2019 that there remained no nominated NED for safeguarding. Support was agreed at board and they were informed that a NED would be identified. The chief nurse was the executive sponsor for safeguarding and had been advocating joined up policies and processes across the STP for safeguarding adults and children. Information provided from the trust stated the clinical safety and effectiveness sub-board received reports and information from all four divisions as well as trust-wide governance committees and triangulated messages and themes. The clinical safety and effectiveness sub-board reported into management board through the integrated performance report (IPR), the safety supplementary reports, slides and the minutes of its meetings. The quality and safety committee, chaired by a NED, received regular reports relating to serious incidents, safety, effectiveness and caring / patient experience. The committee scrutinised and challenged all aspects of the reports against a regular schedule of work. In turn the trust board received and challenged information from the IPR, safety supplementary reports and through the minutes of the management board and the quality and safety committee. There was an established evidence group that had been introduced to review the 82 musts and should actions for the trust outlined in our report, published June 2018. The evidence group provided a robust check and challenge for sign off that actions were complete. We observed this group during our inspection and saw that actions were turned down for completion if the group were not satisfied. The culture within this group prompted open constructive challenge from all grades of staff. For example, we witnessed a junior nurse (band 5) confidently challenge the chief nurse. Daily serious incident group (SIG) meetings had been introduced (Monday to Friday). These were open to all levels of staff to promote shared learning through open discussion. The SIG was chaired by either the chief nurse, medical director or agreed deputies to review all incidents that had occurred in the previous 24 hours. This enabled identification of any immediate safety actions, shared learning and prompt oversight of any emerging themes or issues. In addition, a CEO assurance panel had been set up to review never events and the most complex serious incidents. We were informed, and observed directly, that the SIG meeting was not punitive but promoted constructive challenge and learning. Those involved with the incident were asked to present where possible. Senior staff at Cromer hospital confirmed that they had attended SIG to discuss an incident that had occurred, which meant shared learning across both trust locations. In the two meetings we observed there were incidents where none of the staff involved were present and discussion was postponed. This meant a potential delay in actions and response being taken. There was a medicines incident group which operated in addition to the daily SIG group where all medicines incidents were reviewed. Pharmacy staff told us it could be helpful to hear about incidents as soon as they had happened, and input from the wider team was useful, but there was duplication with the medicines group and the mechanism for sharing learning from SIG was 20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 17 unclear. The chief pharmacist stated that at times it was difficult to free a pharmacist for an hour every day to attend SIG. They were also unclear as to how SIG fitted into the medicines safety group which meets monthly and reviews incident reports. Serious incident reporting and learning was also disseminated through the IPR, governance leads and operational wide learning newsletters (OWLs). From a financial governance perspective, the absence of a financial strategy placed the sustainable delivery of high quality care at risk. The trust was carrying clinical and operational risks associated with a historic lack of capital investment. They had not maintained a clinical equipment replacement programme, and benchmarked poorly against peers for digital maturity (as per Model Hospital 2018.) The Head of Internal Audit opinion for 2017/18 concluded that “the organisation has an adequate and effective framework for risk management, governance and internal control”. However, NHS Improvement identified further enhancements to the framework of risk management, governance and internal control to ensure it remained adequate and effective. Actions had started to raise the profile of both the staff and the patient voice at board however, not all plans were at the point of fruition and opportunities remained for this to be improved. The people and culture committee had recently been introduced and there were further plans in place for the establishment of a patient experience team. The chief nurse informed us that they had taken over the role of executive lead for complaints at the beginning of February 2019 and as such the patient advice and liaison services (PALS) would report into them. They were aware that the policy needed to be updated and a patient experience strategy put in place. A new lead for patient experience was due to start at the trust on 1 March 2019. A partnership arrangement was in place with the local mental health acute trust for the provision of psychiatric liaison services. Staff stated that this was difficult at times due to capacity demands at the local mental health trust. There were often delays in getting specialised patient reviews and access to mental health beds. There was recognition of system wide pressure across Norfolk in relation to access and provision of acute mental health services and the impact this was having on patient care. This risk was escalated at both STP and oversight assurance group, for stakeholder support towards a system wide solution. Despite actions being taken in relation to improving care for patients with mental health concerns at the trust, we found ongoing concerns, during the core service inspections in January 2019, that demonstrated newly formed internal governance processes were not yet fully effective. Systems and process were not consistently followed and significant patient safety risks remained. There was no mental health strategy in place, nor was it included as an enabling strategy in the corporate strategy 2017/18- 2020/21. There was a mental health transformation plan, which was presented as part of a deep dive to the oversight assurance group in August 2018. A performance structure had been introduced focussing on governance, patient safety and increasing the board level of scrutiny. The structure included a mental health operational group, and several sub groups feeding into a mental health board (MHB), that fed into the hospital management board. The MHB ensured partnership working as this was a multi-agency board, with varied stakeholder representation, including the service manager at the local mental health acute trust, and was chaired by the medical director. We reviewed the minutes of the MHB meeting on 14 January 2019. Minutes were of reasonable standard and contained appropriate information, it was evident that terms of reference had been devised. The set agenda included a review of previous minutes and actions, which meant oversight of progress would be monitored moving forward. We saw that the agenda also included a review of complaints, by way of a report from caring and patient experience (CaPE) report, and

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 18 review of the mental health risk register, which was in the process of being devised, and policy approval. Meetings were planned monthly throughout 2019. The trust escalation policy and full capacity protocol had been revised and updated to take account of learning from winter 2017-18. The revised documents simplified and clarified the specific actions required from the emergency department, the site operations team and the divisional medical and nursing teams. Staff had been more informed about the winter plan this year (2018/19). However, they also told us that the timing of implementation could have been improved. It was introduced a week before Christmas and had to be “re-introduced” following the holiday period.

Board Assurance Framework

The board assurance framework (BAF) is a method of setting out the most important risks facing the organisation, the control framework to manage them, any gaps in the control and how the organisation satisfies itself that the controls are working as intended. There was a standard operating procedure for the management of the BAF in place, that had been ratified and approved by the audit committee and was reviewed on 12 December 2018.

The BAF summarises the controls in place to monitor, counter and mitigate the threats to achievements of the strategic objectives. The BAF is kept as a live document, with four finalised versions (fixed points) throughout the year (linked with review by the audit committee). It is then reviewed by the board of directors on a six-monthly basis.

The trust provided their board assurance framework, which detailed four strategic objectives along with a number of identified threats that they are trying to mitigate. A summary of these is below.

• To be a provider of high quality health and care services to our local population • To be the centre for complex and specialist medicine for Norfolk and the Anglia Region • To be a centre of excellence for research, education, innovation and workforce development • To be a leader in the redesign and delivery of health and social care services in Norfolk

Threat Threat description number Strategic objective 1: We will be a provider of high quality health and care services to our local population 1.1 Potential for insufficient strategic and operational focus on delivery of quality and safety, with associated risks to regulatory compliance 1.2 Elective demand continues to outstrip capacity and limits our ability to provide timely access to elective care 1.3 High level and unpredictability of emergency demand creates circumstances that threaten quality of service 1.4 Future investment in services is threatened by challenges to financial sustainability of trust i.e. size of cost improvement programme (CIP) challenge, risk of under- delivery of clinical income, underlying drivers of deficit, absence of capital. 1.5 Financial deficit and inadequate cash may negatively impact on our ability to invest in capital and service developments now, resulting in service failures and storing up costs for the future 1.6 Potential deficit in staff motivation, engagement and resilience may impact on quality

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of care 1.7 Staff vacancies and/or demand outstripping supply has potential quality impact and may result in premium pay costs 1.8 Reliance on recruitment of staff trained by other health education systems threatens ongoing workforce supply Strategic objective 2: We will be the centre for complex and specialist medicine for Norfolk and the Anglia Region 2.1 Variability in clinical outcomes (e.g. stroke, HSMR, cancer access targets) may undermine aspiration to attract additional specialist work 2.2 Uncertainty due to changes in specialist commissioning structures (e.g. Cancer Alliance), plus potential leakage from new prehospital practitioner (NPP) specialist referral pathways, threatens market share and specialist status requiring >1 million population 2.3 Limited capacity of specialist physical infrastructure e.g. CCC, IRU and cath. Lab 2.4 Reliance on external providers to supply post-registration continuing education threatens flow of adequate specialist staff Strategic objective 3: We will be a centre of excellence for research, education and innovation 3.1 Limited functionality of integrated IM&T threatens to restrict research potential and clinical innovation 3.2 Relative immaturity of some elements of education infrastructure 3.3 Relative immaturity of research infrastructure, culture and management processes 3.4 Relative immaturity of innovation and improvement support and culture 3.5 Operational pressures, demands of financial challenge and enhanced regulatory scrutiny limits ability to maintain commitments to education, mandatory training, and appraisal 3.6 Importance of network & partnership relationships – threatened by changes to the National Institute for Health Research (NIHR) and Clinical Research Network (CRN) funding and reputational risk were we to fail as host of the NIHR CRN network or quality improvement partner Strategic objective 4: We will be a leader in the design and delivery of health and social care services in Norfolk 4.1 If the sustainability and transformation partnerships’ (STP) response to the challenges of system redesign is viewed as inadequate this may lead to regulatory intervention. 4.2 We operate in a high-risk environment – our reputation is susceptible to ‘events’ (we need proactive reputational management, internal and external communications, membership and brand management) 4.3 Relative immaturity of our business improvement and service line review processes threatens sustainability of clinical services and limits our system leadership prospects 4.4 Uncertain relationships with our regional partners threatens sustainability of clinical services 4.5 Historical experience of instability in senior team, in context of challenging national picture, plus relative immaturity of our divisional structure

(Source: Trust Board Assurance Framework – October 2018)

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We found that in the October 2018 all 23 threats have remained static in RAG rating. Where additional actions were identified there was a timescale and lead director nominated. There were clear review processes and dates documented for each at relevant review committees and management board. We reviewed the board papers between September 2018 and January 2019. We saw that the BAF was regularly reviewed and used to confirm the boards assurance needs. Gaps in control and assurance were presented to the board, discussed and analysed to underpin decision making and where necessary drive the agenda for the board and relevant committees. For example, there had been a focus on finance (BAF1.4) and emergency performance (BAF1.3) at the hospital management board (HMB) on 16 October 2018. This was reported to inform the board meeting of 26 October 2018. During which it was recorded that the quality and safety risks and those raised by the CQC were included in the BAF. There was consideration and agreement for the schedule of future reports, which was consist with the areas of concern highlighted by the BAF. Management of risk, issues and performance The arrangements for risk, issues and performance management had improved. The governance arrangements, strategy and plan had been reviewed and aligned to focus on safety and quality improvement. This now needed to become embedded across the organisation. At our previous inspection, published June 2018, we had told the trust that it must ensure that there was an effective process for quality improvement and risk management in all departments. The senior leadership team were aware of the wider capacity risks and challenges that the organisation faced. However, they were not aware of the significant issues we found at core service level during the inspection on 22 and 23 January 2019. An external specialist risk management consultancy has been commissioned to review risk management and work with the trust on a training and improvement plan. Divisional groups and trust committees were observed and training was carried out with the divisional triumvirates on 17 December 2018. The trust had reviewed the arrangements for governance and performance management to improve processes to manage current and future performance. A five-year quality strategy was being crafted through a series of staff engagement events. The strategy outlined the strategic intent for quality improvement and set the ambition to build a culture of improvement at all levels, with the patient at the centre. The quality strategy was scheduled for trust board review and comment in January 2019. We reviewed the minutes from the board meeting on 25 January 2019 and saw that this was discussed as scheduled as part of the public board. The report outlined the five-year vision, from 2018 to 2022, and described next steps. This included feedback from staff, service users and stakeholders, engagement sessions to propose quality priorities for 2019-2010 and a gap analysis and implement actions to evidence all elements of quality improvement. There was a quality improvement plan (QIP) in place, that had been designed in consultation with staff and approved by the Board. This set out a number of workstreams, each with executive oversight, to monitor progress against each of the 82 recommendations (must and should actions) from our previous inspection report, published in June 2018. The QIP was reported monthly at the multiagency oversight assurance group. The trust utilised a red, amber, green and blue rating system to indicate progress against actions. Once actions had been taken the objective was rated

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 21 as green however these remained under review and were not marked as complete (blue) until it was evidenced and agreed that the improvement was sustained. This took place at the evidence group where each objective presented was subject to a robust check and challenge. As of February 2019, of the 82 “must and should” actions 44% were blue, 19% were green, 21% were amber and 16% remained red. This meant steady progress was being made towards all improvements required with additional assurance provided through the evidence group. However, whilst overall compliance and improvement was reported and tracked in the QIP, we were concerned that this did not fully reflect our inspection findings. In 2018, we told the trust it must improve in the following areas; staff compliance with mandatory training, staff knowledge, competency and skills in relation to the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS), annual appraisal completion and the utilisation of local audit to support quality improvement. Actions had been taken by the trust to address these concerns, however we found during the core service inspections, in January 2019, whilst improvement was evident in some services this was not consistent across all services inspected with variation seen in certain ward areas and staff groups. Mandatory compliance for medical staff was lower than nursing staff, and below target in several services. Local risk registers were not regularly updated and governance around resuscitation equipment and medication management in relation to monitoring of fridge temperatures was not robust in all areas. We reviewed the March 2019 QIP highlight report to the oversight assurance group and saw that appraisal compliance was rated as blue (complete) at the evidence group on 7 March 2019. Local audit was rated as blue, approved at the evidence group on 17 January 2019, with actions complete or on track for delivery. MCA and DoLS knowledge had been rated as blue in January with two actions relating to quarterly audit and review of process for MCA assessment remaining green as still in progress. Overall mandatory training was 86.9% (rated amber). It was noted in the executive summary that pace of improvement was behind trajectory. Therefore, the monitoring process may not be identifying those individual silo areas of concern. Senior management committees and the board reviewed performance reports. The agenda at each board meeting included a review of the integrated performance report. This covered quality, safety and effectiveness, caring and patient experience, performance and productivity, workforce and finance. The divisional management structure was clinically led and each had the responsibility for quality and safety across the trust. The divisions reported through the clinical safety and effectiveness sub-board and the weekly hospital management board. The trust organisational development programme included developing clinical leaders across all divisions, through the triumvirate models. The chief nurse had implemented a structure for nursing, midwifery, allied health professionals (AHPs) and all other professions to communicate and share good practice; this included junior staff, clinical leaders, specialist practitioners and a senior multi-professional practitioner forum. This already had impact in creating a leadership cascade and access to the chief nurse, deputy chief nurse and divisional nurse directors. There had been a decline in infection prevention and control processes. In February 2018, the trust received a green rating following an NHS Improvement (NHSI) inspection. Due to the concerns raised from our previous inspection, the NHSI internal risk assessment matrix was triggered and the rating was reduced to amber. NHSI re-inspected the trust in January and February 2019 at which point the trust was rated as red. Concerns included a lack of staff awareness of their roles and responsibilities in relation to IPC and a lack of response to previous

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 22 findings. The chief nurse is the director of infection, prevention and control (DIPC). They informed us that this had been taken seriously and a rapid recovery programme had commenced. This was monitored through the quality improvement plan and twice weekly meetings. Several actions had been instigated, that included, but were not limited to, formation of an IPC cleanliness task and finish group, additional training for senior staff, housekeepers and IPC link nurses and education for all staff around roles and responsibilities. This was included as a deep dive at the oversight assurance group on 21 March 2019. This meant that there was now a clear governance and audited action process for infection prevention and control. Whilst systems were in place to identify learning from incidents, complaints and safeguarding alerts, we were informed that these remained an area for further improvement. The trust safeguarding lead informed us that, at the time of inspection, there was an increased risk in three areas; monitoring safeguarding referrals for children and young people (CYP), the complaints system and mandatory training compliance in specific areas across the trust. However, they were working with the chief nurse who was addressing these issues across the STP. There had been a change in the referral methods requested by the multiagency safeguarding hub (MASH) in Norfolk. Two methods, an electronic referral and telephone referral, were now in use. CYP referrals had been changed to telephone referrals only, whilst adult safeguarding referrals remained electronic. Several communications had gone out to the clinical teams to make them aware of this change and request made that staff record when a CYP referral had been raised on an incident form to enable tracking. The safeguarding lead was confident that referrals were being made, however they were less sure that these were all being entered on the electronic incident system. This meant that there was a potential gap in the ability to track and trace referrals for children and young people which limited the system capability to identify learning and trends. This was raised at the multiagency oversight group on 21 February 2019 as an area to be addressed with the support of clinical commissioning group (CCG) partners. The safeguarding lead had also recognised a gap in relation to the complaint process and safeguarding. They told us that they were only contacted when a complaint had ‘safeguarding’ specifically mentioned. They were not certain that the complaints team would necessarily recognise a concern that may constitute a safeguarding and there was currently no clear action for dealing with this. However, this was likely to be addressed as the chief nurse had taken over as executive lead for complaints in February 2019. There had been an increased focus on safeguarding training across the trust. Work had been undertaken to review the safeguarding mandatory training programme. The safeguarding lead was aware that in areas of high pressure, such as the emergency department, it was difficult for staff rostering to ensure that staff could be released for three hours. There was a change to the programme planned for May 2019 to bring the trust in line with the new intercollegiate document. All staff, in the trust, will be trained in level three safeguarding for adults and children, and the programme will take place over a whole day which the safeguarding lead hoped may address some of the rostering issues. The executive directors were agreed on the most significant risks for the organisation. Each had their own particular focus, but had articulated staffing, talent management, digital maturity, electronic observations, capacity and finance as the greatest risks. These were all reflected on the risk register and in the BAF. The board felt that the risks were now accurately representative and appropriately discussed. A high-risk tracker, for risks graded 15 or above, was included in the integrated performance report, included in the papers for board meetings.

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The chief executive described the combination of volume demand and the trust ability to deal with the volume as increased capacity pressures. They recognised the need to rebalance capacity across the three acute Norfolk hospitals and that collaboration would be essential to long term sustainability. Whilst the three hospital operating sites would be retained, the STP would move to a ‘hospital chain’ model, which would centralise commissioning, with a focus on patient pathways, clinical sustainability and financial flows. This would ensure sustainable Norfolk hospital services, with a specific focus on emergency care, cancer care and maternity services. Seeking to manage elective and non-elective demand and therefore reduce the current system deficit. As such the trust was undertaking lead provider work across the two other acute hospitals and we saw evidence of this in the private board papers of 28 September 2018. The ideal being to bring dividends to patient care and safety by enhancing services across the three acute trusts. The CEO was clear that this would be about producing three vibrant sites and reducing the threat of centralisation. Opportunities were actively being explored with one of the other acute trusts. These included a joint cardiology service and exploration of the opportunity to appoint a joint director of workforce. As outlined above, a significant amount of work had taken place to improve risk, issues and performance oversight however this needed to become embedded. For example, during the core service inspection on 22 and 23 of January 2019, we found several areas of inconsistency. These included risk registers not updated or reflective of all risks, in outpatient services, critical care, surgery and children and young people’s services. The board were not fully sighted on all the issues we raised within the emergency department but they were immediately responsive. We reviewed the board minutes from September 2018 to January 2019. We found that certain matters arising had been carried over throughout that period. One related to ‘equipment failure/unavailability’ accounting for around 20% of cancelled operations. Given the constraints on capital expenditure it had been requested that the two issues be reported separately. However, this remained an action as it was proving difficult to implement on the IT system, impacted by the fact that a clinical equipment replacement programme had not been maintained. Whilst this evidenced towards the overall digital risk at the trust, it failed to address the question around equipment concerns. At our previous inspection, published June 2018, we had raised concern that the trust secretary had re-written clinical and financial reports for hospital management board, which had caused a divide and breakdown of communication amongst the executive team. We reviewed the board minutes from September 2018 to January 2019 and found that they still wrote several reports, the majority being on behalf of NEDs rather than executive directors. For example, the audit committee meeting (12 September 2018) report and quality and safety committee meeting (14 September 2018) report for board on 28 September 2018. We were provided at this inspection with the trust secretary job description. We noted that this was under review, however the job purpose outlined “facilitate the smooth operation of the Trust’s formal decision making and reporting processes” and “provide relevant support to executive directors, non-executive directors and governors in performing their duties”. The executive team were aware that there was a risk of change fatigue and that the upcoming changes with future appointments of a new chair and chief executive officer carried their own challenges. The ongoing staff engagement, leadership and development in the strength of the divisions would be essential in providing stability. Emergency planning and business continuity processes were in place. Monitoring was undertaken through a local resilience working group and reporting line, via the risk oversight committee, up to

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 24 trust board. Internal plans had been made in preparation for Brexit, such as identified routes for cascading information across the organisation, as well as consideration of the impact on the wider health economy. For example, potential workforce constraints in care homes, as many across Norfolk have high percentage of staff that are EU nationals, that may not have support to stay. A health resilience workshop was being considered both internally and with NHS partners. Finances Overview

Historical data Projections Previous Last Financial This Financial Next Financial Financial metrics Financial Year Year (2017/18) Year (2018/19) Year (2019/20) (2016/17) Income £564.1m £586.7m £604.9m - Surplus (deficit) (£24.9m) (£19.6m) (£53.6m) - Full Costs £589.0m £606.3m £658.4m - Budget (or budget (£25.0m) (£26.2m) (£53.6m) - deficit)

The Trust’s deteriorating financial position suggested that processes for managing risks, issues and performance were not fully effective. The trust provided some context in their return about the move from £19.6m deficit 2017/18 to £53.6m deficit 2018/19: In 2017/18 the trust was in receipt of the non-recurrent funding of £10.6m relating to sustainability and transformational fund (STF) and winter. There was none assumed for the current year as the trust could not agree the control total. In addition, £12.6m relating to an opening balance sheet review was released into 2017/18 with nothing expected in 2018/19. This leaves £10.8m, being the inclusion of £7m for risk for CQC and Winter pressures and £3.8m of other cost pressures - all net of a savings target of £30m. (Source: Routine Provider Information Request (RPIR) – Finances Overview tab) We reviewed the trust risk register. The size and complexity of the cost improvement programme (CIP) and potential failure of the organisation to live within the challenging financial targets were recognised as threats to the financial stability of the trust. The trust had established a programme management office (PMO) to be responsible for monitoring and reporting on progress against the trusts financial improvement and QIP. Benefits of a PMO included the provision of a proven method of delivering projects, and therefore CIPs and savings, for the trust. To pace plan development and provide a consistent way of planning monitoring and reporting to make accountability clearer. We saw that the PMO included a clear governance structure from divisional delivery up to the financial improvement programme board, HMB and ultimately trust board. There had been several external consultancy services undertaken to support the identification and development of improvement programmes and recovery plans, which carried a financial implication. The chief finance officer (CFO) commenced work on 26 August 2018 and had brought experience and strength to the board. They were aware of the need to strengthen and develop the board to reach the point of sustained internal regulation, to reduce reliance on external consultancy, and for improved contingency planning. For example, with regard to equipment, they were looking at managed service equipment contracts. There were arrangements in place to consider impact on patient care against every CIP proposal to ensure that patient safety would not be compromised. This was through clinical quality impact

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 25 assessments (CQIA) sign off at a combined financial improvement and CQIA approval committee. Membership of this committee was both operational and clinical; the CFO (chair), the chief operating officer (COO), chief medical officer (vicechair), chief nurse and head of PMO. Divisional representatives attended to present initiatives. We reviewed the quality and safety committee meeting minutes between September 2018 and January 2019. The PMO report, including CQIA updates, were set items on the agenda and were included in the minutes.

Trust corporate risk register

The trust provided a document detailing their 22 highest profile risks. Each of these have a current risk score of 12 or higher.

Risk Risk Last ID Description score level review (current) (target) date 10 wards do not have all of their 6-bedded bays fitted with doors which can be closed. This can pose an infection control risk in the event of an outbreak of an infection or disease on the ward. 348 12 4 20/07/2018

Wards affected: Brundall, Buxton, Blakeney, Coltishall, Denton, Dilham, Docking, Dunston, Earsham, and Gunthorpe. Safe staffing levels (nursing) on wards. There is currently a very high level of vacant trained and untrained nursing posts.

383 This is likely to result in gaps in ward and 12 6 20/07/2018 departmental rota’s which we will not be able to fill with bank staff. Staffing agency price caps may affect our ability to adequately cover all necessary clinical shifts with agency staff. We must be able to demonstrate that patient acuity 384 is properly assessed in the drive to optimise 12 8 20/07/2018 patient experience and safety. A deferral of the annual refurbishment programme was requested in respect of Pharmacy Production, as project team are planning requirements – two 397 12 3 23/07/2018 options being considered, one for compliance work only and other for complete scheme to be undertaken. The orphanage and radiotherapy IT server rooms have been subject to an external review, which has 474 identified the presence of a water pipe in the open 12 3 02/08/2018 ceiling void in the room. This connects from the main water pipe to charge the sprinkler system. In

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the event of failure of the pipework, water will be discharged onto the servers and electrical equipment below. The PACS IT server room has been subject to an external review, which has identified that there is no fire suppression system in place within the room. 475 12 4 02/08/2018 The room has already been subject to a risk assessment in relation to inadequate air conditioning, which can cause the electrical equipment to overheat. There is an increasing prevalence of cybercrime 499 12 4 02/08/2018 and cyber-attacks against the NHS. If the trust does not respond positively and effectively to the key themes resulting from the 2017 Staff Survey 526 12 8 25/07/2018 Then staff may not feel supported and valued in the workplace. This would potentially compromise recruitment, retention, morale and service delivery. GP reference data held on the Somerset Cancer Register is no longer updated from PAS. This means that patients with suspected and confirmed cancer potentially have incorrect GP details held on the system. The main risks are that clinical 541 12 3 02/08/2018 documentation such as MDT outcomes could be sent to the wrong GP and that the wrong GP is recorded against the patient in nationally submitted datasets such as the Cancer Waiting Times dataset. NHS England have set a mandatory training compliance rate of 85% for all staff who require PREVENT Level 3 training. NHS England have requested that trusts in high priority areas provide monthly assurance and recovery plans to both the CCG lead and NHS 559 12 4 20/07/2017 England via the RPCs. NNUH is not in a priority area, however CCG and CSU have requested a trajectory to demonstrate how the trust will achieve 85% compliance by March 2018. Currently it is projected that the NNUH will achieve a maximum of 73.1% compliance by March 2018. The trust’s escalation policy is in place to support the organisation at times of peak demand by 564 identifying non-inpatient areas that can be opened 12 9 25/07/2018 as “escalation areas” out of hours to temporarily accommodate inpatients in order to support patient

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flow and ease pressure at the front door. These ‘escalation areas’ are not fully equipped or staffed to provide inpatient care. Adequacy and effectiveness of monitoring compliance with infection prevention and control 565 12 12 08/12/2017 standards related to hospital acquired and hospital associated infections. If staff do not maintain compliance with statutory and mandatory training commensurate with their 568 role, then they will not be able to maintain skills, 15 9 25/07/2018 competence and knowledge

The pressure to meet key local & national performance targets against a backdrop of 571 increased demand for services in relation to: ED 16 9 25/07/2018 four-hour target, 18-week RTT, and two-week cancer waits. The financial sustainability of the trust is threatened by: • the size and complexity of the Cost 572 20 8 01/10/2018 Improvement Programme • potential failure of the organisation to live within the challenging financial targets There is a need to ensure sufficient numbers of staff are in place to deliver the services for our 573 12 6 25/07/2018 patients. Workforce demand exceeds supply for certain staff groups. Ensure robust processes for monitoring contractual 574 12 8 25/07/2018 requirements (including CQUIN) If the trust continues to host key clinical and non- clinical systems within the IT server estate using Microsoft Windows Server 2003 operating system 593 beyond the end of June 2018 (the DoH extended 12 4 28/03/2018 support ceases), then these systems cannot be protected from and become increasingly vulnerable to cyber threats. If levels of non-elective demand are such that the trust's capacity to respond is exceeded to the point where the Escalation Policy and Full Capacity 596 12 9 25/07/2018 Protocol are enacted, then the delivery of specialist services and elective programmes are compromised. Fit testing for FFP3 masks is a mandatory 597 requirement for all clinical staff in areas identified 12 6 23/07/2018 as high risk. Fit testing is a requirement at

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departmental induction, and must be repeated if there are any aesthetic/cosmetic changes to staff members’ appearance.

If compliance with fit testing for FFP3 mask continues to be low across high risk areas, then in the event of an infectious outbreak, staff will be working in exposure prone environments without sufficient protection.

If the trust does not have a clear central record of where peripheral decontamination activities are 598 undertaken (i.e. outside the CSSD/EDU 12 6 25/07/2018 environment) then the trust cannot be assured of the quality of decontamination practices across the Trust. If the trust does not invest and continues to utilise aged IT infrastructure (Hardware, servers and back 610 20 10 02/08/2018 up environments) the infrastructure will fail and critical services will not function

(Source: Trust Corporate Risk Register up to 30/09/2018)

Since our previous inspection in 2018, some areas including surgery, the emergency department and diabetes had additional support from the pharmacy team, and there was an increase in the service at weekends. However, specialist pharmacy support to the critical care unit did not meet the minimum standards of the UK Clinical Pharmacy Association critical care education group and although the critical care department had developed a business case for a pharmacy team, the posts had not been advertised at the time of inspection.

The trust was not on track to meet the antimicrobial stewardship commissioning for quality and innovation (CQUIN) although they had reduced the usage of broad spectrum antibiotics. The electronic prescribing and medicines administration (EPMA) system had recently been upgraded but there were system glitches which the trust was working with the provider to address. For example, the EPMA did not support prescribers in reviewing intravenous (IV) to oral antibiotics.

There was a pharmacy risk register in place. The highest risk was an operational problem in the pharmacy production unit, meaning that some products were delayed in being purchased and others had a restricted shelf life. This was under review at the time of inspection. There was also a problem with mould in the pharmacy production unit, at the time of inspection. Many avenues had been explored to identify and remove the cause, however this was still unresolved. The trust had temporarily outsourced services where possible, for example the production of total parenteral nutrition (TPN). However, in the cancer unit, the high volumes of chemotherapy needed and clinical trials rely on in-house production. The trust had not found a commercial or other NHS supplier who had the capacity to deliver the volumes required. They were mitigating the risk by short shelf life, review of procedures, cleaning and refurbishment and specialist advice but were aware that a longer-term solution would need to be found which may extend to building a new unit.

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Information management The trust collected, managed and used information well to support all its activities, using secure systems with security safeguards. Digital immaturity was an increased risk that was recognised by the board. The joint appointment, with the STP, of a chief information officer (CIO) and a digital strategy indicated that steps were being taken to address sustainability as part of a wider transformation programme. The trust board recognised that reliable, good quality information was a fundamental requirement for the effective and prompt treatment of patients, clinical governance, management requirements and service agreements for health care planning and accountability. Information provided stated that all information within the trust was derived from individual data items, collected from numerous sources and must comply with internal and national data standards, including information governance guidelines. All data collection and information systems that hold trust data were covered by policy, whether they were paper based, media or electronic. Data quality was critical for the trust’s ability to manage both existing data and to incorporate new data management demands as services evolve. Data cleansing was required to preserve the integrity of data, when deploying new systems and retiring legacy systems, and migrating data into multiple key systems to ensure continuity with the patient administration system (PAS). The trust monitored performance by key performance indicators and performance metrics such as dashboards and the integrated performance report. The trust operated a key system process through an annual audit program via data quality. The data quality department run two audit programmes on a continuous cycle, with the aim to ensure maintenance of data that is accurate, valid, reliable, timely, relevant and complete. Information provided was that the audit progression, outcomes and agreed action plans / recommendations would be added to a data quality performance dashboard with agreed deadlines set for corrective actions to be implemented. Progression plans would then be discussed at the information governance (IG) steering group that reported to the non-clinical safety group. Historically the trust had invested in information systems on a departmental basis as need and investment allowed. This meant that, as reported above, not all systems integrated well to allow specific data analysis. There was an aged infrastructure including end-user devices, networks and server estate. This meant that data was reactionary, semi-automated and resource intensive. The trust now had a chief information officer (CIO) as part of the executive team. This was a joint appointment with the STP. In November 2018 a digital strategy was drafted that outlined an investment profile and programme of work to improve the current digital environment, information systems, infrastructure and support function as part of a wider transformation programme across Norfolk. The governance for the priority of investment and delivery for information systems was through the information management and technology (IM&T) programme board, the clinical informatics committee, hospital management board and then trust board. A deep dive into the digital strategy was presented at oversight management group meeting on 15 November 2018. The trust was rated as fifth lowest for digital maturity in the Model Hospital data, and the bottom in comparison with other large university hospitals. The other two acute trusts in Norfolk were rated in the bottom five alongside the trust (one lowest and one the third lowest). The digital strategy outlined a transformation plan that identified team development, business

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 30 relationships, governance and process and continuous improvement as the enablers towards six strategic objectives: 1. Digitally empowered people 2. Digitally enabled workforce 3. Integrated and collaborative care 4. Informatics 5. Innovation Lab and 6. Digitally enabling infrastructure

The strategy outlined the status and proposed actions for each objective. It was recognised that urgent requirements included electronic document management (EDM), electronic observations and theatres. As well as the opportunity for a collaborative STP wide acute electronic patient record (EPR) procurement and implementation. We saw that the strategic outline case for a joint Norfolk and Waveney hospitals electronic patient record system was presented to the trust board on 25 January 2019. The corporate risk register included consideration of security breaches and the risk of a ransomware attack would pose to the IT infrastructure and patient data. Information provided to NHS Improvement (NHSI) had been consistent and generally reliable. The trust has been transparent and responsive in addressing NHSI information requests. Financial reporting to the finance committee was of a reasonable standard and highlighted key risks and issues, enabling committee members to oversee and challenge performance. However, there were some areas identified where financial information could be improved to support management decision making, for example service line reporting and investment appraisal.

Engagement There had been actions taken to improve engagement with staff. However, there was a limited approach to sharing information with and obtaining the views of patients, relatives and people who use the services. A series of actions in response to the 2017 national staff survey results had been initiated, with key areas of focus for improvement in culture, working environment and leadership. There had been a major focus on improving staff communication and cultural development in the trust, based around the PRIDE values and visible and approachable leadership. Despite this results in the 2018 staff survey in relation to the theme of staff engagement were just below the average for similar acute trusts with a score of 6.8 against an average of 7.0. This had remained relatively static since 2014, and had dropped slightly from the 2017 score of 6.9. There were nine questions relating to staff engagement. The new format of the national staff survey demonstrated that the trust had remained below the average of other acute trusts in eight of the nine for the past three years. The trust was closest to the average in relation to Q21c “I would recommend my organisation as a place to work” scoring 61.9% against the average of 62.6%. There was one question where the trust had consistently scored above the average. This was Q21d “If a friend or relative needed treatment I would be happy with the standard of care provided by this organisation”, in 2018 the trust achieved a score of 75.7% in comparison to the average of 71.3%. The three questions where the trust scored closest to the worst, which meant these were areas of particular focus for improvement, were Q2b “I am enthusiastic about my job”

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 31 scoring 71.4%, with the worst being 69.3%. Q2c “time passes quickly when I am working”, scoring 74%, with the worst being 72.6% and Q4d “I am able to make improvements happen in my area of work” scoring 46.7% in comparison to the worst at 45.5%. We had reported in June 2018, that the trust must review the bed management and site management processes within the organisation to increase capacity and flow and improve the relationship and culture between the site management team and clinical teams. The trust had implemented a winter team, in January 2019, to establish a leadership structure, in line with the divisions. The team would support optimum operational flow and improve communication between site operations team and clinical teams. The team consisted of a triumvirate; an associate medical director, nursing director and operational director. Whilst the winter team felt this had been beneficial they stated that communication around the decision to implement the team could have improved. They had found staff were initially quite suspicious and felt “done to”. The team were working hard to address this but were aware that it would take time to build staff trust. They saw their purpose as one of helping the teams seek solutions to issues, not to fix them for them. With the hope that by investing in, listening and empowering staff sustainable change would be achieved. They were aware that this would require an assurance framework and robust performance accountability framework which was to be work in progress. There was recognition that there had been a lack of performance management in the past to challenge poor behaviours. There was no formalised organisational development framework in place however, coaching for departmental leaders had just been agreed. Initial actions for the winter team included setting the strategic direction, goals and vision to identify initial deliverables that everyone could sign up to. At the time of inspection, we found that there was limited opportunity for patient and service user engagement. People who used the service, and those close to them and their representatives were not actively engaged and involved in decision making to shape services and culture. The executive team were aware of this and informed us plans were in place to address the issue however many of these were yet to be realised. A lead for patient experience had been appointed and was due to start at the trust on 1 March 2010. There was then an intention to recruit a head of patient experience and build a team which would have the responsibility for the patient experience strategy. There was a “Patient and Public Involvement Strategy” version 8 in place which was due for renewal on or before the 01 December 2018. We reviewed the caring and patient experience (CaPE) minutes between October 2018 and January 2019 and could not see that this had been undertaken. It had been recognised as an action, in the 12 December 2019 CaPE meeting minutes, that there was nothing recorded on the high-risk tracker about the lack of patient voice or experience. It was documented “Need to add that we have a silent patient voice around patient engagement and experience – this need to be added, key concern from the regulators”. The caring and patient experience report was included as part of the integrated performance report (IPR) to board. We reviewed board meeting minutes between September 2018 and January 2019. The chief executive had shared a patient letter at the public trust board on 28 September 2018 that expressed great appreciation for “excellent treatment” and “respect and politeness shown” however this was not a regular occurrence. Proposals for patient story discussions at board meetings was discussed at the quality and safety committee meeting on 29 November 2018, as an opportunity to increase the ‘patient voice’, in accordance with the recommendation from the Kings Fund report. It was minuted that the trust would report on this proposal at the board meeting on 30 November 2018 with the

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 32 recommendation that full details should be included in board development proposals for approval in December. However, we could not see that this had taken place. The board had considered the creation of a people and organisational development committee at the meeting on 28 September 2018 and it was recorded that the action was closed however the actual outcome was not documented. We saw from the board meeting of 25 January 2019 that a proposal to re-establish and extend the role of the patient panel at the trust. The patient panel would consist of a group of volunteers who represented patients, families and carers. The panel would identify means of improving the patient experience, encourage their application, and represent patients’ interests in all areas. Panel members would monitor the operation and standard of the hospital’s services by receiving monthly presentations from clinical teams, providing wide-ranging advice and assistance to many projects, departments and sites. They would also serve as “the voice of the patient” and as a “critical friend” to the trust. Reflections on the development and assurance visits were included for the first time in the board meeting minutes of 25 January 2019. The chief nurse informed us that they were also aware of the need to engage with children that receive care and the “voice of the child”. They had become the chair of the children’s board and a strategy had been finalised and was due to be presented at the hospital management board on 5 March 2019. We noted that an action had been identified in the CaPE, 10 October 2018, meeting minutes that a transition / young person’s strategy needed to be drafted, approved and in place by May 2019 as currently there was “no medium or long-term strategy in place”. This was then reviewed again on 9 January 2019 and the action closed as complete, with oversight to be through the transition group meeting, with work streams allocated through the children’s board meeting in March 2019. We found there was a lack of involvement from the council of governors, despite this being an established group. New roles and responsibilities of governors were set out in the Health and Social Care Act 2012. As outlined in the “Your statutory duties, A reference guide for NHS foundation trust governors August 2013” governors perform a pivotal role in providing local accountability. Feedback from the council of governors (verbal) was included as part of the set agenda for each public board meeting however the meeting minutes did not record any specific detail of any feedback provided to the trust. For example, the minutes of the 25 January 2019, referred to a governors meeting that had occurred two days earlier “The next meeting of the Council will take place on 23 January 2019.” In the minutes of 30 November 2018, it was recorded that the board were informed “that there has been a recent informal meeting at which the governors were updated on developments in the Trust.” There was no record recorded at all for the public board meeting of 28 September 2018, and no record at any of the private board meeting minutes we reviewed. There was transparency and openness with all stakeholders around performance which was clearly demonstrated at the monthly multiagency oversight assurance group meetings. Governors were represented at the oversight meetings. The trust used a community pharmacy information system to refer patients to their local pharmacy for medicines review on discharge. Pharmacy team members attended regional meetings on specialist subjects for information sharing and peer support.

Learning, continuous improvement and innovation

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The trust had taken steps to increase the focus on continuous learning and improvement at all levels of the organisation. The trust continued to drive a collaborative research approach as part of their strategy. There was a workforce and education strategy (WES) 2017-2022 in place, following a period of consultation. The director of workforce stated that year one had focused on investing in the team and people focus policies, and that this year the aim was to bring year one to “life”. We reviewed the “WES year one report – 2018 achievements” and saw that activities and updates were provided against all five goals. These included, but were not limited to, workforce planning and scope, recruitment, temporary workforce consideration, leadership management and development, embedding PRIDE values, “leading with PRIDE” and health and wellbeing of staff. The chief nurse was committed to investment in staff development across all levels. They had started to strengthen the organisational systems to support improvement and innovation. They had actively looked at the nursing skill mix against the ward acuity requirements and found that there were gaps where the skill mix did not match. They had where necessary taught the divisional nursing directors (DNDs) to do this. The DNDs were encouraged to undertake cross directorate projects and 360-degree feedback had been undertaken. There were plans to begin the same process at matron level and to introduce an 18-month preceptorship programme for senior nurses (band 6). At the time of inspection one band 5 nurse and one midwife were taking part in the Florence Nightingale programme, a bespoke leadership development programme. An outline business case was in the process of being drafted for an advanced care assistant role (band 2 / 3) in caring for patients living with dementia, learning disabilities and mental health concerns. The first dementia care clinical nurse specialist in the trust, commenced in role on 24 September 2018. This was an internal appointment that demonstrated, talent mapping and career progression. The chief nurse was also promoting several initiatives to enhance practitioners’ skill and evolvement of roles, including some clinical academic posts and doctorate programmes for nurse development. The nurse associate training programme was launched on 13 September 2018. The trust had appointed the first UK nurse registrar in dermatology. The nurse registrar role is primarily aimed at providing a structured professional route to encourage the retention of nurses already highly trained but to support them to the next level of their career whilst keeping them in the frontline of clinical services, research and service development. We were informed that this was the first time that a formal nurse registrar programme has been funded and supported in dermatology and was seen as an alternative to recruiting straight into a nurse consultant role. The skin cancer specialist nurse had started a three-year programme to qualify as a nurse consultant in dermatology which will involve completing an advanced practitioner MSc postgraduate qualification with the University of East Anglia (UEA), with a focus on service development within dermatology. The trust also had in place eleven nurse endoscopists and were in discussion with the Joint Advisory Group (JAG) about the formation of a faculty of nurse endoscopists, that JAG may support as a pilot. Progress had been made on embedding processes for reviewing and investigating deaths to meet national guidelines. The medical director was the executive lead for mortality; they had undertaken structured judgement review (SJR) training to ensure an understanding of the process. The SJR methodology is based upon the principle that trained clinicians use explicit statements to comment on the quality of healthcare in a way that allows a judgement to be made that is reproducible. A mortality committee was in place with regular attendance from representatives for each division, mortality reviewers, the lead for mental health and learning disability nurse. SJR training had been 20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 34 provided to staff involved, alongside root cause analysis training and human factors training. Clinicians carrying out investigations were independent of the care provided as much as possible. Processes were in place for investigating learning disability and mental health deaths and these were automatically included as serious incident reviews. A cross system group was also in place where deaths were discussed. Attendance included commissioners, staff from other acute and community providers and colleagues from mental health.

Mortality data was reviewed by the board monthly through the integrated performance report, which included HSMR and SHMI data. In addition, the integrated performance report included a mortality dashboard, which provided a summary of deaths reviewed under the SJR methodology, including separate data for learning disability deaths, maternity deaths, paediatric deaths, and mental health deaths. The dashboard included data on the percentage of deaths that were deemed avoidable. At the time of inspection, the trust was in the process of reviewing the clinical governance processes and were working with the divisions to increase ownership of the mortality review process and to make the process business as usual. The medical director felt that they had improved the processes for learning from incidents and mortality. They felt that the clinicians investigating deaths were open to identifying deaths as ‘potentially preventable’ and were focused on identifying any issues of concern. For example, the trust had identified themes from mortality reviews such as fluid management, deteriorating patients, acute kidney injury and sepsis. They stated that work programmes had been developed for each of the themes identified. There was recognition that certain areas could be improved. There was no non-executive director (NED) nominated lead for mortality but there were plans to introduce this once the new NEDs had been appointed. The medical director also discussed plans to have relative and carer involvement on the mortality committee, however there had been no interest from any relatives/carers to date. The trust was in the process of appointing a member of staff to liaise with families. They were also awaiting the appointment of a medical examiner role which it was hoped would help improve cross system working and liaison with families. It was noted on the mortality dashboard, presented to trust board on 21 December 2018, that a need had been identified for strengthened mortality surveillance processes for improved accuracy of information from all sources to identify themes and trends in a consistent way. The implementation of an electronic records system would improve the mortality review process and enable more effective, efficient and consistent data analysis. The current system was difficult and time consuming as it required manual checking of paper records. The quality and safety improvement (QI) strategy was drafted to support the trusts “journey to outstanding” and described the strategic intent for continuous improvement and innovation setting an ambition to build a culture of improvement at all levels. The strategy outlined that teams would be supported and coached by a multi professional QI faculty in the science of improvement using standardised tools such as the Institute for Healthcare Improvement (IHI) Model for Improvement, After Action Review, Learning from Excellence and Always Events. These provide frameworks and structures that can be adapted to review, debrief, learn from events and accelerate improvement. The aim of the trust was for this not to be a short-lived trend, but that QI will become a frontline activity, and a consistent part of the culture where staff are directly able to listen to patients and implement changes that make a real difference to patient care. The trust was building a network of staff throughout the organisation based on The Health Foundation’s Q initiative. ‘Q’ aims to connect people with improvement expertise across the UK,

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 35 fostering continuous sustainable improvement in health and care. The aim was to replicate this model within the trust and ensure opportunities were available for people to come together as an improvement community to enhance their improvement skills, share ideas, collaborate to innovate and improve the quality and safety of care. The trust continued to promote learning via Organisation Wide Learning (OWL) bulletins which brought safety issues to the attention of all staff. They had also introduced a series of interactive presentations, and undertook a number of ‘roadshows', in which staff were invited to drop by and look at display stands and discuss the methodology and approach with programme participants or members of the QI Faculty. The pharmacy team were Involved with the UEA and other local providers in a health partnership project on medicines optimisation (opioid reduction, deprescribing, genetic testing etc). Clinical research is an essential component of high quality care provision. The trust was well situated within the Norwich research park and research featured in the organisations corporate strategy. The Quadram Institute, a new food and health research and endoscopy centre opened in autumn 2018, with the trust being one of the founding partners. The centre for food and health research brings together Quadram Institute Bioscience (formerly the Institute of Food Research), the Norfolk and Norwich University Hospitals’ regional gastrointestinal endoscopy facility and aspects of the University of East Anglia’s Norwich Medical School and the Faculty of Science. Information provided by the trust stated that it was at the forefront of a new interface between food science, gut biology and health, developing solutions to worldwide challenges in food-related disease and human health. There were plans to work with industry to become a leading international hub for food and health science, combining scientific excellence and clinical expertise, to deliver better patient care whilst accelerating innovation. Staff would work closely with the plant and crop researchers, creating a powerful plant-food-health pathway to deliver clinically-validated strategies to improve human nutrition, health and wellbeing and with the food industry, healthcare and allied sectors to transfer its scientific knowledge into practice. The endoscopy service and centrum simulation suite had been open since December 2018. The chief executive included this in their report to the board on 25 January 2019 as a further step towards the strategic objective to become a centre of excellence for research, education and innovation. At the time of inspection, the trust was out to advert for a director of research. Complaints process overview The trust had a formal process in place for complaints through the patient advice and liaison services (PALS). As reported above, the chief nurse had taken over the role of executive lead for complaints at the beginning of February 2019. As a routine all complaints were shared with the clinical teams across the divisions with the divisional nurse directors holding the responsibility to follow up progress on actions to ensure learning was undertaken. This was evidenced in the caring and patient experience sub-board (CaPE) meeting minutes. We found during the core service inspection in January 2019 that complaints were investigated appropriately, handled and responded to effectively and that lessons were shared in the majority of services. However, in the maternity service, we found that promoting complaints was not embedded with staff and not all patients knew how to make complaints. Response times were

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not always in line with local policy in all services, for example in surgery and outpatients. A monthly update report of complaints trends and themes was undertaken and reported to the caring and patient experience sub-board (CaPE) as part of a regular reporting cycle. It was agreed that response times for complaints should be included as a standing agenda item for CaPE at the 10 October 2018 meeting. We reviewed the CaPE meeting minutes between October 2018 and January 2019 and found that PALS enquiries, compliments and complaints, themes and trends were standing items. Whilst number of complaints, location and response times were featured we could not see that trend analysis was documented which meant a potential risk to opportunities for shared learning across services. We reviewed the annual report, dated 3 May 2018. The annual report reflected a comparison, with previous years, of the number of complaints received each month, the incident date that the complaint related to, the top five locations and subjects of complaint. In addition, the report detailed the number in comparison to trust activity and a link to some examples of evidence of learning that had occurred from complaints. The trust webpage had a “you said, we did” section that provided examples of feedback received and how these were used to make change. Recent examples from December 2018 and January 2019 related to cancellations of appointments and concern around patient care and discharge process. The trust was asked to comment on their targets for responding to complaints and current performance against these targets for the last 12 months.

Current Question In days performance What is your internal target for responding to complaints? 3 days 100% More than What is your target for completing a complaint 50% within 25 56% days If you have a slightly longer target for complex complaints n/a n/a please indicate what that is here Number of complaints resolved without formal process in the 2,538 - last 12 months (November 2017 to October 2018)?

(Source: Routine Provider Information Request (RPIR) – Complaints Process Overview tab)

Number of complaints made to the trust

The trust received 1,015 complaints from October 2017 to October 2018. Surgery received the most complaints with 245 (24.1% of total complaints).

Number of Percentage Core Service complaints of total AC - Surgery 245 24.1% AC - Medical care (including older people's care) 239 23.5% AC - Outpatients 186 18.3% AC - Urgent and emergency care 124 12.2% Provider wide 50 4.9% Other 47 4.6% AC - Maternity 43 4.2% AC - Diagnostics 31 3.1% AC - Services for children and young people 27 2.7%

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AC - Gynaecology 18 1.8% AC - Critical care 5 0.5% Total 1,015 100.0%

(Source: Routine Provider Information Request (RPIR) – Complaints tab)

Compliments

From October 2017 to September 2018, the trust received a total of 528 compliments. A breakdown by core service can be seen in the table below:

Number of Percentage Core service compliments of total AC - Urgent and emergency services 151 28.6% AC - Surgery 109 20.6% AC - Medical care (including older people's care) 88 16.7% AC - Outpatients 59 11.2% AC - Diagnostics 33 6.3% AC - Maternity 32 6.1% Provider wide 26 4.9% AC - Gynaecology 15 2.8% AC - Services for children and young people 10 1.9% AC - Critical care 5 0.9% Total 528 100.0%

The trust has stated that the feedback and thank you comments that they receive are varied, although they have identified that phrases used frequently relate to the professionalism, kindness and caring of staff.

The Trust also maintains a monthly PRIDE awards recognition scheme alongside its annual staff awards. The trust has identified that the feedback and comments received about teams and individual staff often relate to compassion, quality of care and professionalism.

(Source: Routine Provider Information Request (RPIR) – Compliments)

Accreditations

NHS trusts are able to participate in a number of accreditation schemes whereby the services they provide are reviewed and a decision is made whether or not to award the service with an accreditation. A service will be accredited if they are able to demonstrate that they meet a certain standard of best practice in the given area. An accreditation usually carries an end date (or review date) whereby the service will need to be re-assessed in order to continue to be accredited.

The table below shows which of the trust’s services have been awarded an accreditation.

Link to CQC core Accreditation scheme name Service accredited service Endoscopy Suite - Achieved 23rd June 2016. AC - Medical care Joint Advisory Group on Endoscopy (JAG) (including older GRS Certificate achieved people's care) 14th August 2017.

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Imaging Services Accreditation Scheme Radiology- we have had this AC – Diagnostics (ISAS) for 6 years Biochemistry, haematology, and microbiology at NNUH all at 30th September 2018 Cellular pathology (consisting histopathology and Clinical Pathology Accreditation and its cytopathology). Accreditation successor Medical Laboratories ISO - was obtained in January 15189 2017, after inspection in August 2016. This has been maintained in two subsequent surveillance visits in August 2017 and August 2018. CHKS provides accreditation service for ISO 9001; we use AC - Medical care CHKS Accreditation for radiotherapy and oncology services BSI. Our current ISO 9001: (including older 2015 certificate runs until people's care) 26/04/19. Yes - accredited - 10th MacMillan Quality Environment Award AC – End of life care (MQEM) December 2014 Audiology outpatient IQIPS via UKAS for adult rehabilitation AC - Outpatients and paediatric audiology department - 2016 Central Sterilisation Services EN13485 (2016) - Department

(Source: Routine Provider Information Request (RPIR) – Accreditations tab)

We saw from our review of trust board meeting minutes that accreditations and congratulations were included. For example, it was noted in the chief executive report, on 28 September 2019, that the cellular pathology team had successfully renewed their UKAS accreditation. The assessors had complimented the department on professional, knowledgeable and competent staff. In the 25 January 2019 papers the chief nurse reported that the trust’s pressure ulcer collaborative team was awarded the peer nominated award for the most innovative pressure ulcer reduction initiative with the ‘zero tolerance challenge’ showing signs of success. The trust website also featured innovative treatment projects that were recognised at national health awards. In the Health Service Journal’s (HSJ) Value in Healthcare Awards the older people’s medicine (OPM) team were nominated in the ‘Acute Service Redesign’ category for their service innovation which had focussed on enhancing the care provided for Norfolk’s frail and older patients. In June 2018 the urology department were highly commended for the innovative work introducing the Urolift procedure. This is a minimally invasive ambulatory treatment for severe urinary tract symptoms from benign prostate hyperplasia (BPH), which has meant rapid symptom relief and quicker recovery for patients. At the time of inspection, the dementia team had just been entered for a national award.

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Acute services

Urgent and emergency care

Facts and data about this service Details of emergency departments and other urgent and emergency care services The main urgent and emergency care services at the trust are primarily provided at Norfolk and Norwich University Hospital. The type 1 service includes the following: • Six resus spaces including a paediatric assessment space and cardiac bay • 16 majors cubicles • Six minors cubicles and plaster room • Five urgent care centre (UCC) rooms for GPs co-located within minors • Eight rapid assessment and treatment (RAT) cubicles • 12 clinical decisions unit spaces • Four older people’s ED (OPED) cubicles, along with two OPED side rooms and dedicated waiting area. The emergency department (ED) majors and minors, clinical decisions unit (CDU), paediatric ED and the older people’s ED (OPED) were open 24 hrs per day, seven days per week. The main ED also had two cubicles dedicated to supporting ambulatory care patients. The urgent care centre (UCC) is a general practitioner (GP) led service operating 8am to 11am seven days per week. Appropriate patients requiring GP intervention are streamed to the UCC on arrival at the ED. The acute medical unit (AMU) has two wards (male and female) with a total of 55 beds. AMU receives GP referrals by a telephone service as well as referrals from the ED and ambulatory emergency care (AEC). The AEC operates from 8am to 8pm Monday to Friday, and 9am to 5pm Saturday to Sunday and uses nine trolley spaces on the AMU. The children’s emergency department (CED) sees approx. 25,000 children per year. The CED has four treatment cubicles, one escalation of care cubicle (1 bed space and 1 resuscitaire), two isolation cubicles and one quiet room. (Source: Routine Provider Information Request (RPIR) – Acute context)

Activity and patient throughput Total number of urgent and emergency care attendances at Norfolk and Norwich University Hospitals NHS Foundation Trust compared to all acute trusts in England, August 2017 to July 2018

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From August 2017 to July 2018 there were 134,398 attendances at the trust’s urgent and emergency care services as indicated in the chart above. (Source: Hospital Episode Statistics)

Urgent and emergency care attendances resulting in an admission

The percentage of A&E attendances at this trust that resulted in an admission decreased in 2017/18 compared to 2016/17. In both years, the proportions were higher than the England averages. (Source: NHS England)

Urgent and emergency care attendances by disposal method, from August 2017 to July 2018

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* Discharged includes: no follow-up needed and follow-up treatment by GP ^ Referred includes: to A&E clinic, fracture clinic, other OP, other professional # Left department includes: left before treatment or having refused treatment (Source: Hospital Episode Statistics) During our inspection we spoke with spoke with 50 members of staff including matrons, nurses, health care assistants, doctors, junior doctors, consultants, paediatric doctors and nurses. We also spoke with housekeeping staff, reception staff, a safeguarding lead for children, advanced care practitioners, psychiatric liaison staff, agency mental health assistants, flow coordinators, occupational therapy staff, the chief of division, operations manager, ambulance staff, hospital ambulance liaison officer (HALO) and chaplain. We inspected the urgent care centre, resuscitation area including a paediatric assessment space and cardiac bay, majors and minors, rapid assessment and treatment (RAT), the clinical decisions unit (CDU), paediatric ED, the older people’s ED (OPED) and reception areas. Following our previous inspection in October 2017, we issued a S29A Warning Notice having found some significant concerns in the urgent and emergency service. We followed these up at a focused inspection in November 2018 and found that the trust was partly compliant. However, we remained concerned around the care and assessment for patients with mental health concerns, environments used for patients at risk of deliberate self harm, isolation procedures and governance and quality assurance were not fully effective. We issued two requirement notices, which we followed up at this inspection. Whilst we found some improvement we remained concerned and issued a further S29A Warning Notice on date 22 March 2019. The trust is required to make improvements and provide CQC with an action plan. We spoke with eight adult patients, relatives and two children to ask about their experience of care. We also spoke with senior staff who were part of the trust’s new “Winter Management Team” specifically formed by the trust to deal with access and flow through the department due to the number of patients attending the emergency department. We reviewed 24 sets of patient records in relation to their care, treatment and medication. We also reviewed policies, procedures and guidelines within the emergency department and reviewed equipment to ensure it was clean and serviced in line with manufacturer guidance.

Is the service safe? By safe, we mean people are protected from abuse* and avoidable harm.

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 42

*Abuse can be physical, sexual, mental or psychological, financial, neglect, institutional or discriminatory abuse. Mandatory training The service provided mandatory training in key skills to all staff, but did not ensure everyone completed it.

Mandatory training completion rates The trust set a target of 90% for completion of mandatory training.

Trust level A breakdown of compliance for mandatory training courses at September 2018 at trust level for qualified nursing staff in urgent and emergency care is shown below:

Number Number of of staff eligible trained staff Completion Trust Met Name of course (YTD) (YTD) rate Target (Yes/No) Health and Safety (Slips, Trips and Falls) 201 243 83% 90% No Fire Safety 189 243 78% 90% No Adult Basic Life Support 188 242 78% 90% No Infection Prevention (Level 2) 179 240 75% 90% No Medicine management training 174 234 74% 90% No Blood Transfusion 162 224 72% 90% No Equality and Diversity 167 243 69% 90% No Resuscitation 112 164 68% 90% No Manual Handling - Object 2 3 67% 90% No Information Governance 153 243 63% 90% No Venous Thromboembolism 143 231 62% 90% No Manual Handling - People 144 240 60% 90% No Prevention & Management of Aggression 130 231 56% 90% No Clinical Record Keeping 130 240 54% 90% No Infection Prevention (Level 1) 0 1 0% 90% No

In urgent and emergency care the 90% target was met for none of the 15 mandatory training modules for which qualified nursing staff were eligible. A breakdown of compliance for mandatory training courses at September 2018 at trust level for medical staff in urgent and emergency care is shown below:

Number Number of of staff eligible trained staff Completion Trust Met Name of course (YTD) (YTD) rate Target (Yes/No) Health and Safety (Slips, Trips and Falls) 69 73 95% 90% Yes Blood Transfusion 58 70 83% 90% No 20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 43

Medicine management training 56 70 80% 90% No Clinical Record Keeping 51 70 73% 90% No Fire Safety 53 73 73% 90% No Infection Prevention (Level 3) 45 66 68% 90% No Venous Thromboembolism 47 70 67% 90% No Adult Basic Life Support 43 70 61% 90% No Equality and Diversity 44 73 60% 90% No Information Governance 43 73 59% 90% No Manual Handling - Object 41 70 59% 90% No Resuscitation 27 48 56% 90% No Prevention & Management of Aggression 9 48 19% 90% No

In urgent and emergency care the 90% target was met for one of the 13 mandatory training modules for which medical staff were eligible. (Source: Routine Provider Information Request (RPIR) – Training tab)

Norfolk and Norwich University Hospital A breakdown of compliance for mandatory training courses at September 2018 at Norfolk and Norwich University Hospital for qualified nursing staff in urgent and emergency care is shown below:

Number Number of of staff eligible trained staff Completion Trust Met Name of course (YTD) (YTD) rate Target (Yes/No) Health and Safety (Slips, Trips and Falls) 198 236 84% 90% No Fire Safety 184 236 78% 90% No Adult Basic Life Support 181 235 77% 90% No Medicine management training 170 227 75% 90% No Infection Prevention (Level 2) 172 233 74% 90% No Blood Transfusion 162 224 72% 90% No Equality and Diversity 164 236 69% 90% No Resuscitation 105 157 67% 90% No Manual Handling - Object 2 3 67% 90% No Information Governance 148 236 63% 90% No Venous Thromboembolism 143 231 62% 90% No Manual Handling - People 137 233 59% 90% No Prevention & Management of Aggression 130 231 56% 90% No Clinical Record Keeping 123 233 53% 90% No Infection Prevention (Level 1) 0 1 0% 90% No

At Norfolk and Norwich University Hospital the 90% target was met for none of the 15 mandatory training modules for which qualified nursing staff were eligible. Note: The trust was unable to provide site level training data for medical and dental staff working in urgent and emergency care. (Source: Routine Provider Information Request (RPIR) – Training tab) 20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 44

The trust provided updated information for mandatory training courses for qualified nursing staff in urgent and emergency at Norfolk and Norwich University Hospital as of January 2019.

As of January 2019

Training module name Staff Eligible Completion Trust Met trained staff rate target (Yes/No)

Health & Safety 209 245 85% 90% No Fire Safety - 1 Year 195 245 80% 90% No Resuscitation - Adult Basic Life 180 242 74% 90% No Support - Practical Infection Prevention and Control - 178 240 74% 90% No Level 2 Equality & Diversity 181 245 74% 90% No Information Governance 160 245 65% 90% No Manual Handling Patient Contact 158 242 65% 90% No Resuscitation - Paediatric Basic Life 96 167 57% 90% No Support - Practical Prevention & Management of 131 233 56% 90% No Aggression

The 90% target was not met for any of the mandatory training modules. The resuscitation – paediatric basic life support and prevention and management of aggression modules had the lowest completion rates. The trust provided updated information for mandatory training courses for medical and dental staff in urgent and emergency at Norfolk and Norwich University Hospital as of January 2019.

As of January 2019

Training module name Staff Eligible Completion Trust Met trained staff rate target (Yes/No)

Health & Safety 67 74 91% 90% Yes Fire Safety - 1 Year 62 74 84% 90% No Resuscitation - Adult Basic Life 51 70 73% 90% No Support - Practical Equality & Diversity 51 74 69% 90% No Information Governance 49 74 66% 90% No Manual Handling Non Patient 46 70 66% 90% No Contact Resuscitation - Paediatric Basic Life 30 47 64% 90% No Support - Practical Infection Prevention and Control - 42 66 64% 90% No Level 3 Prevention & Management of 9 46 20% 90% No Aggression

The 90% target was met for the health and safety module but not for any of the other mandatory training modules. The prevention and management of aggression modules had the lowest completion rate of 20%. (Source: Data Request – DR05/DR11) 20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 45

At our last inspection we found the staff training rates were below the trusts compliance targets. During this inspection data provided by the trust showed compliance levels still fell below the required compliance levels. Staff received training through on line learning, face to face training sessions and during mentor sessions with nominated experienced staff. All staff we spoke with were positive about the trusts training activities and could demonstrate how they could access a wide range of learning materials on the trusts intranet system. The service had two full time clinical educators who worked in the ED and staff told us they were beneficial in terms of providing ongoing support and access to learning. Their role was to increase staff compliance with mandatory training and offer opportunities for staff development All staff we spoke with understood the trusts sepsis management process, when to implement this and how to use the sepsis screening tool. Sepsis education was incorporated into junior doctor training days and junior doctors completed an “ALERT” course which included local sepsis processes. Sepsis key points were included within annual mandatory resuscitation training program for all staff including screening processes, emergency cascade and use of the sepsis six bundle. Medical staff we spoke with told us that teaching and training for doctors was positive at the trust. Teaching sessions were delivered on serious incidents, clinical updates, and other core skills. Managers were responsive to requests for additional training and staff valued the mentor days, which they felt added to their core skills and provided opportunities to discuss any areas of interest and seek feedback on their current competencies. Safeguarding Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service provided training on how to recognise abuse but not all staff had completed the training. Safeguarding training completion rates The trust set a target of 90% for completion of safeguarding training. Trust level A breakdown of compliance for safeguarding training courses at September 2018 at trust level for qualified nursing staff in urgent and emergency care is shown below: Number Number of of eligible staff trained staff Completion Trust Met Name of course (YTD) (YTD) rate Target (Yes/No) Safeguarding Children (Level 1) 1 1 100% 90% Yes Safeguarding Children (Level 2) 73 80 91% 90% Yes Safeguarding Adults (Level 2) 196 242 81% 90% No PREVENT - Level 3 170 240 71% 90% No Safeguarding Children (Level 3) 91 161 57% 90% No PREVENT - Level 1&2 0 1 0% 90% No Safeguarding Adults (Level 1) 0 1 0% 90% No

In urgent and emergency care the 90% target was met for two of the seven safeguarding training modules for which qualified nursing staff were eligible. It should be noted that for two of the

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 46 modules where completion rate did not meet the trust target there was only one member of staff eligible (PREVENT - Level 1&2 and Safeguarding Adults (Level 1)). A breakdown of compliance for safeguarding training courses at September 2018 at trust level for medical staff in urgent and emergency care is shown below: Number Number of of eligible staff trained staff Completion Trust Met Name of course (YTD) (YTD) rate Target (Yes/No) Safeguarding Children (Level 2) 10 13 77% 90% No Safeguarding Children (Level 3) 36 57 63% 90% No PREVENT - Level 3 36 62 58% 90% No Safeguarding Adults (Level 2) 38 70 54% 90% No

In urgent and emergency care the 90%% target was met for none of the four safeguarding training modules for which medical staff were eligible. (Source: Routine Provider Information Request (RPIR) – Training tab) Norfolk and Norwich University Hospital A breakdown of compliance for safeguarding training courses at September 2018 at Norfolk and Norwich University Hospital for qualified nursing staff in urgent and emergency care is shown below: Number Number of of eligible staff trained staff Completion Trust Met Name of course (YTD) (YTD) rate Target (Yes/No) Safeguarding Children (Level 1) 1 1 100% 90% Yes Safeguarding Children (Level 2) 73 80 91% 90% Yes Safeguarding Adults (Level 2) 190 235 81% 90% No PREVENT - Level 3 163 233 70% 90% No Safeguarding Children (Level 3) 87 154 57% 90% No PREVENT - Level 1&2 0 1 0% 90% No Safeguarding Adults (Level 1) 0 1 0% 90% No

At Norfolk and Norwich University Hospital the 90% target was met for two of the seven safeguarding training modules for which qualified nursing staff were eligible. Note: The trust was unable to provide site level training data for medical and dental staff working in urgent and emergency care. (Source: Routine Provider Information Request (RPIR) – Training tab) The trust provided updated information for safeguarding training courses for qualified nursing staff in urgent and emergency at Norfolk and Norwich University Hospital as of January 2019.

As of January 2019

Training module name Staff Eligible Completion Trust Met trained staff rate target (Yes/No)

Safeguarding Children Level 2 76 77 99% 90% Yes Safeguarding Adults - Level 2 209 242 86% 90% No

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PREVENT Level 3 181 239 76% 90% No Safeguarding Children Level 3 100 164 61% 90% No

The 90% target was met for one of the four safeguarding training modules for which qualified nursing staff were eligible. The trust provided updated information for safeguarding training courses for medical and dental staff in urgent and emergency at Norfolk and Norwich University Hospital as of January 2019.

As of January 2019

Training module name Staff Eligible Completion Trust Met trained staff rate target (Yes/No)

PREVENT Level 3 42 60 70% 90% No Safeguarding Children Level 2 9 13 69% 90% No Safeguarding Adults - Level 2 47 70 67% 90% No Safeguarding Children Level 3 38 57 67% 90% No

The 90% target was not met for any of the safeguarding training modules for which medical and dental staff were eligible. (Source: Data Request – DR06) The trust had an identified safeguarding nurse, in addition to the trust's designated child protection lead. The safeguarding lead reported directly to the trusts chief nurse and line managed the safeguarding team which comprises of child, adult and maternity safeguarding services and the mental capacity and deprivation of liberty matron. We spoke with the safeguarding children lead and reviewed the safeguarding children’s policy and safeguarding adult’s policy, both policies were up to date and in line with current guidance. Staff received training on how to recognise and report different forms of abuse, including domestic violence, female genital mutilation (FGM), modern slavery, child sexual abuse and fabricated illness amongst other key areas. Staff knew and could explain to us their responsibilities in relation to FGM, how to contact the safeguarding teams and make a safeguarding referral. We noted key guidance on safeguarding displayed on walls around the ED, posters next to staff work stations and on the trusts intranet site. Between July and December 2018, the ED made 92 safeguarding adult referrals and 390 safeguarding children referrals. The trust had a clinical guideline in place outlining organisational responsibility in the identification and reporting of children who were reported to or had been identified as a victim of sexual exploitation. Out of hours, staff told us they would contact the local children's social services and or the Police. At the time of our inspection staff used a paper based flagging system to record safeguarding concerns within the patient’s record. However, the trust had launched a new safeguarding checklist. which staff completed on the electronic patient record system. This aimed to replace the paper based system. Staff we spoke with were clear on its purpose and how to use the system to record a safeguarding concern and complete an on-line safeguarding referral form.

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Staff could identify patients who attended the ED more frequently, as each ED attendance was flagged within the patient electronic record. Children who attended the ED more than three times in a three-month period were automatically highlighted for a safeguarding review by staff and the trust policies gave clear guidance to staff on how to follow up on any frequent attenders. If staff were concerned about a possible non-accidental injury to a child, they immediately referred this to a senior consultant and completed an on-line referral form to the internal safeguarding team. Staff also considered the needs of patients during pregnancy, and the unborn child, as well as looking for patients who may have a mental health need and if these may place a child or other family members at risk. Staff we spoke with described the safeguarding team as engaged in ED day to day work, visible within the department and always willing to offer advice or guidance. Safeguarding staff reviewed patient records daily to look for any concerns and liaised with external agencies where appropriate. For example, contacting the Police for a domestic violence issue. Staff could download an NHS app to their mobile phone, which gave up to date details in relation to safeguarding adults and children, including guidance on the types and recognition of abuse and how to make a referral. This meant that staff had access to guidance on safeguarding remotely through their mobile phones. The trust held safeguarding assurance meetings every other month which was attended by senior representatives from all divisions who took responsibility for ensuring information and agreements reached at the meeting were fed back through their retrospective divisional boards and governance structures. The safeguarding team provided monthly safeguarding reports to the clinical safety and effectiveness board. The trust chief nurse sits on the Norfolk Safeguarding Children's Board and attended the safeguarding adult, health executive safeguarding adult’s alliance (HESAA) meeting. The safeguarding team also represented the organisation by attending local safeguarding adult and children working groups in partnership with the Norfolk Safeguarding Children's and Adult Boards. Safeguarding issues were a standing item on the corporate directorate agenda and within the trusts divisional clinical governance structure. Safeguarding training was part of the mandated trust training programme and was monitored by both the local clinical commissioning groups dashboard, divisional performance meetings and by the clinical safety and effectiveness board. Cleanliness, infection control and hygiene The service controlled infection risk well. Equipment and premises were clean. Staff used control measures to prevent the spread of infection. Since our last inspection there had been a significant improvement in standards of cleanliness and hygiene within the emergency department. Housekeeping staff were visible in the department throughout our inspection, engaged in cleaning activities and emptying waste bins frequently during the day. We checked cleaning schedules and noted records were up to date and reflected the various areas of the ED that required cleaning. We also reviewed additional cleaning rotas supplied by the trust which showed staff completed cleaning schedules in line with daily cleaning schedules, this was an improvement on our last inspection. Staff used I am clean stickers to indicate that cleaning had taken place, we noted these were in date and easily visible to staff. Data supplied by the trust following our inspection showed hand hygiene compliance in the main emergency department for October 2018 was 97%, with November and December at 100%. The older persons emergency department achieved 100% compliance in October 2018, and 95% in 20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 49

December 2018, no results were provided for November 2018. The children’s emergency department achieved 94% compliance in November 2018 and 100% compliance in December 2018. Between January 2018 and December 2018, the trust identified three patients with positive C. difficile results. C.Difficile is a bacterium affecting the digestive system; it often affects people who have been given antibiotics and has the capability of causing harm to patients. All patients were tested on admission to the ED, none of the patients had been an inpatient at the trust in the six weeks prior to ED admission. Staff were aware of and practiced infection prevention and control in line with national guidance. Handwashing facilities and hand sanitiser stations were readily available throughout the department and the “Five Moments of Hand Hygiene” guidance was displayed at all hand washing stations. Five Moments for Hand Hygiene defines the key moments for hand hygiene, overcoming misleading language and complicated descriptions. Hand washing facilities, alcohol gel and hand conditioner was available throughout the department. We observed staff following hand hygiene, ‘Bare below the Elbow’ guidance, and wearing personal protective equipment (PPE) such as gloves and aprons whilst delivering care in line with the trust’s policy. The department had a plentiful supply of PPE and we observed staff restocking this as required. Clean linen was accessible and stored on covered trolleys. Staff told us that even in busy times they could replenish their linen stock. All the store rooms we observed were clean, tidy and well ordered. Toys held in the children’s emergency department waiting areas were routinely cleaned and we checked cleaning rotas that showed staff cleaned these in line with cleaning schedules. Staff cleaned equipment thoroughly between patients to reduce the risk of cross contamination and restocked equipment where appropriate. The department had dedicated cubicles for patients with a possible infection. All patients were screened as part of their initial assessment to assess whether they had any infections or had visited any overseas locations. Staff we spoke with could explain the protocol for isolating patients with a possible infectious disease. We observed appropriate signs for an infective patient being nursed in the ED and reminding staff of the actions they must follow to minimise the risk of cross contamination. All the disposable cubicle curtains we checked were clean and in date for renewal and disposal. The curtains would collapse if pulled upon, to reduce the risk of ligature. Environment and equipment The service had systems, processes and practices in place to manage the environment and equipment to keep people safe. Since our last inspection, the trust had invested significantly in improving the physical environment and creating clinical areas to deal with the increased demand in patient numbers. This included the urgent care centre (UCC), children’s’ ED (CED) and rapid assessment and treatment (RAT) area. There was a dedicated entrance for ambulance and air ambulance arrivals which led to the resuscitation and RAT areas that enabled critically ill patients to be triaged and transferred to the correct area. Patients self-presenting used the main reception areas for the ED and UCC. The main ED entrance was staffed by the reception team 24 hours a day, seven days per week. The UCC operated between 8am and 11am seven days per week and was staffed by the reception 20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 50 team. Outside of these hours the UCC was closed and all patients were redirected to the main ED reception. Some areas of the ED were covered by internal and external closed-circuit television (CCTV) and access into the ED clinical areas was by swipe card to manage patient and staff safety. Staff raised concerns that the RAT area was not covered by internal CCTV, and had no alarm systems for calling for assistance should a patient deteriorate or become violent towards staff. We raised this issue with the trust at the time of our inspection. The trust was aware of the staff concerns and recognised that the new environment required further improvements to meet the needs of the patients and staff. The CED was accessed by the main hospital corridor, this had CCTV and swipe card access. Reception staff covered reception from 8am to 11pm daily, out of hours access was through a buzzer and CCTV intercom system. The OPED and CDU were accessible by swipe card access and were adjacent to the CED and main older care ward. Throughout our inspection we found the environment to be free from clutter. The layout of the departments was appropriate for supporting easy access to diagnostic and imaging services. It provided X-rays for adults and children. Staff were confident that access to computerised tomography (CT) or magnetic resonance imaging (MRI) scans was not delayed when required for urgent investigations. Staff told us that children using these facilities used the same entrance as adult patients. However, patients were always escorted by a member of hospital staff when going for an imaging service. There were three dedicated rooms within the ED for mental health assessments. All were in line with the Royal College of Emergency Medicine (RCEM) mental health tool kit for improving care in emergency departments. The tool kit states any assessment area needs to be safe for staff, and conducive to valid mental health assessment and importantly, the assessment room must be safe for both the patient and staff. This was an improvement on our last inspection, however we found staff did not routinely use these areas for patients with mental health needs and instead used them for escalation areas during increased times of demand. We checked 20 items of electrical equipment and consumables within the department and found that electrical equipment had been safety tested and serviced appropriately and consumables were in date for use. Staff had access to adequate supplies of available, accessible and suitable equipment, including resuscitation equipment. There was a schedule for regular checks for equipment which had been followed and recorded in all areas we inspected. Staff had used a highlighter pen to highlight dates on equipment packaging to show clearly when consumables, for example catheters, or airway equipment needed replacement. All the department’s emergency resuscitation trolleys were tamperproof and records we reviewed demonstrated that in January 2019, staff completed daily checks of emergency resuscitation equipment. Dedicated, appropriately equipped interview rooms were available in the emergency department for patients with mental health needs. These areas complied with the requirements of Health Building Note Building Note 15-01: accident & emergency departments 17.9 (2013) which states an interview room should be considered for use by staff for talking to disturbed and distressed patients and relatives. However, at the time of our inspection we identified that the trust was using these rooms for escalation to deal with patient demand and not specifically for distressed or disturbed patients. One of the rooms had been specifically equipped for the psychiatric liaison staff to use as an office area, this was not in use, despite reassurance from the trust at our 20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 51 previous inspection that staff from the psychiatric liaison service would use this area to support patients and staff. We also found staff supporting a patient with mental health needs in a relative’s room, rather than one of the mental health rooms. The room was on a main corridor within the ED, and staff were seated outside the room with the door open whilst the patient laid on a mattress on the floor. The patient could be seen by any patients and staff walking through the ED, which did not promote the patient’s dignity and staff did not use the dedicated mental health rooms for their intended purpose. However, staff told us this was part of the patients care plan and that they often used this area for this purpose. The service had sufficient equipment specifically for accommodating bariatric (Clinically obese) patients, including trolleys, and wheelchairs however staff told us these had to be hired in. Due to the separation of the adult and CED, there was clear audio and visual separation between adults and children and appropriate seating and space for children and families to wait. This was an improvement on our last inspection. The clinical decisions unit (CDU) was being used to support patients with mental health needs, we had concerns that this area of the department had a number or ligature points. Staff told us that patients were observed by staff in this area and that the trust had implemented a policy to improve observation and risk management of patients with mental health needs to mitigate any risks of self-harm. During our inspection we identified that patients could not always be seen by staff and there was an ongoing risk of self-harm. This issue was on the trusts risk register and staff were implementing the trust policy. The trust had effective systems and processes in place for the segregation and management of clinical and non-clinical waste. Staff had access to sharps bins throughout the department and we found them to be labelled and dated in line with trust policy.

Assessing and responding to patient risk The service did not respond appropriately to changing risks to patients who used the services. Emergency Department Survey 2016 The trust scored about the same as other trusts for all of the five Emergency Department Survey questions relevant to safety. Question Score RAG Q5. Once you arrived at the hospital, 8.4 About the same as other how long did you wait with the trusts ambulance crew before your care was handed over to the emergency department staff? Q8. How long did you wait before you 6.5 About the same as other first spoke to a nurse or doctor? trusts Q9. Sometimes, people will first talk to a 6.6 About the same as other nurse or doctor and be examined later. trusts From the time you arrived, how long did you wait before being examined by a doctor or nurse? Q33. In your opinion, how clean was the 9.0 About the same as other emergency department? trusts Q34. While you were in the emergency 9.8 About the same as other

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 52 department, did you feel threatened by trusts other patients or visitors? (Source: Emergency Department Survey (October 2016 to March 2017; published October 2017) Median time from arrival to initial assessment (emergency ambulance cases only) The median time from arrival to initial assessment was better than the overall England median in October 2017 and worse than the England median in December 2017. For this metric, the trust has data for only two months for the period from October 2017 to September 2018.

Ambulance – Time to initial assessment from October 2017 to September 2018 at Norfolk and Norwich University Hospitals NHS Foundation Trust

(Source: NHS Digital - A&E quality indicators)

Percentage of ambulance journeys with turnaround times over 30 minutes for this trust Norfolk & Norwich University Hospital From November 2017 to October 2018 there was a stable trend in the monthly percentage of ambulance journeys with turnaround times over 30 minutes at Norfolk and Norwich University Hospital. In October 2018, 72.9% of ambulance journeys had turnaround times over 30 minutes.

Ambulance: Number of journeys with turnaround times over 30 minutes - Norfolk & Norwich University Hospital

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Ambulance: Percentage of journeys with turnaround times over 30 minutes - Norfolk & Norwich University Hospital

(Source: National Ambulance Information Group)

Number of black breaches for this trust A “black breach” occurs when a patient waits over an hour from ambulance arrival at the emergency department until they are handed over to the emergency department staff. From September 2017 to September 2018 the trust reported 4,686 “black breaches”. The highest number of black breaches were reported in December 2017 (798 breaches), followed by January 2018 (624 breaches) and February 2018 (539 breaches). The trust reported that in September to November 2017 black breaches occurred mainly because of workforce and batching issues. From December 2017 to September 2018 the trust reported that workforce, batching, and ED exit block were the main reasons for black breaches occurring.

(Source: Routine Provider Information Request (RPIR) - Black Breaches tab)

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During our inspection we noted ambulances queueing frequently outside the emergency department and the hospital was on Opal Alert due to capacity issues and flow throughout the hospital. At one point there were 13 ambulances queuing, with three of the ambulances holding patients on the ambulance for almost three hours until space became available in the RAT area. The ED had no specific guidance for managing patients waiting on ambulances, or identifying patients most likely to deteriorate. Staff had no dedicated safety checklist to assess patients waiting to be seen on an ambulance or to review them in order of risk. Ambulance staff we spoke with told us if they had a concern they would escalate this to the nurse in charge of the RAT area. However, ambulance staff said they were not always able to get a clinician who was prepared to review a patient and it depended very much on capacity and who was on duty. Senior staff we spoke with said some medical staff were concerned about their own professional indemnity and unsure if they could assess or treat patients waiting in ambulances. Following our inspection, we raised our concerns to the trust regarding this risk. They responded by putting in place a standard operating procedure to increase the oversight of patients and identify patients most likely to deteriorate. We carried out an unannounced follow up inspection of the ED on 14 February 2019 and staff gave mixed feedback on the new procedures. Generally, staff told us that they had not used the new system, or had training in its operation and that it very much depended who was on duty as to whether the system would be used. The RAT area was described to us as a nurse led service with support from a doctor between 9am to 9pm. The Royal College of Emergency Medicine (RCEM) guidance says that streaming should be performed as soon as possible and ideally be within 15 minutes of the patient’s arrival in the ED and that all patients attending the ED should be registered within five minutes of arrival. We noted that patients were routinely registered by the hospital within five minutes of arrival, however patients were not always streamed within 15 minutes. The RAT triage role was performed by nurses with a blend of training and bandings, from a band five nurse to a band seven nurse. There was no consistency in terms of the staff members skills or competencies when carrying out this role. The triage nurse was recording the handover from the ambulance crew, and then the patient was directed to a RAT cubicle for initial assessment by another nurse or health care assistant. The triage nurse did not complete any observations on the patient, at times patients were being booked in and ambulance staff wheeled the patient to a bay without the nurse directly seeing the patient. Once patients were booked into the department, the notes were placed into an in-tray in arrival order, staff would then get to the patients as soon as they had finished with a previous patient. This meant there was a risk that patients could deteriorate whilst waiting to be seen. Staff did say they would highlight patients who they were concerned about, and could use a sticker on the patient file to give them a clinical priority. This process was inconsistent and we noted that staff had completed incident reports in relation to patients who had been deemed fit to sit and waited to be seen, who then deteriorated due to serious underlying conditions that had not been diagnosed on assessment. The doctor assigned to the RAT area was not routinely in place due to a shortage of medical staff across the ED. On the last day of our inspection the doctor had been moved to support the CED and no direct medical support was in place within the RAT area. This impacted on clinical decisions and we noted patients waiting for up to eight hours before a decision was made on their care pathway. Patients remained in the RAT area under observation by the RAT team until there was an opportunity for the patients to be moved.

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Staff we spoke with said the lack of senior clinical decision makers was evident across the ED with RCEM guidance suggesting between 48 and 52 senior clinical decision makers for a similar sized ED. The trust had between 22 and 24 senior clinical decision makers at the time of our inspection. The trust used the early warning score system (EWS). An early warning score is a guide used by medical services to quickly determine the degree of illness of a patient. It is based on the vital signs of respiratory rate, oxygen saturation, temperature, blood pressure, pulse and heart rate. In March 2019, the trust is moving to NEWS2, the latest version of the National Early Warning Score (NEWS), a system to standardise the assessment and response to acute illness. This will bring the trust in line with other care providers locally, for example the ambulance trust, and standardise early warning scores during initial and ongoing patient assessments. Since our last inspection the trust had appointed a dedicated sepsis improvement and audit specialist nurse and continued development of electronic sepsis screening within the ED using the electronic patient record to identify patients at risk of sepsis. The sepsis screening tool sticker system triggers when any patient has an EWS greater than four, alerting staff to the need to follow the sepsis pathway. The trust used a ‘2222’ sepsis emergency cascade process with the attendance of the critical care outreach team or site practitioner to attend a septic patient. The trusts sepsis lead consultant had established a working group with the local ambulance trust with the goal of unifying sepsis processes pre-hospital and in-hospital and streamlining the pathway for patients identified as having red flag sepsis in the community once they arrive in ED. Children were immediately directed to the CED on arrival. All patients were triaged on arrival and transferred to the area best suited to provide treatment. We reviewed the notes of two children in relation to CEWS (Children’s Early Warning Score), staff triaged the children within fifteen minutes, complying with the standards for children, and young people in emergency care settings set by the Royal College of Paediatrics and Child Health (RCPCH 2012). All areas where fully stocked with equipment, emergency trolleys and medicines to treat patients. Patients who were critically ill or required resuscitation were brought directly into the resuscitation area. This facility was appropriately equipped for the resuscitation of adults, children and babies. If arriving by ambulance, telephoned ahead, which allowed the department to prepare to receive the patients. The trust has introduced the UK’s first emergency department dedicated to patients over the age of 80, the older person emergency department (OPED). When a patient over 80 years arrived at the ED, staff streamed the patient go to OPED, where there was a multi-disciplinary team consisting of ED consultants, consultant geriatricians, emergency and older people’s medicine nurses waiting to provide care for them. Patients who required a longer admission would be admitted directly to one of the specialist older people’s wards. A comprehensive geriatric assessment (CGA) was undertaken by a team of doctors, nurses, therapists and pharmacist on every frail patient attending the hospital which had been shown to reduce the need for hospital admission in future. These measures helped to improve experience, broaden patient choice and increase independence for this patient group. The trust had a process for screening elderly patients for frailty which could trigger further multidisciplinary team (MDT) assessments. Staff monitored behavioural changes use of the abbreviated mental test score (AMTS) for patients presenting with altered cognition. The ED used a standard operating procedure (SOP) for the management of patients requiring specific mental health pathways. The SOP set out roles and responsibilities, timescales for response, communication and documentation, escalation, and reporting processes. The ED had access to psychiatric liaison staff 24 hrs per day, seven days per week based within the hospital. 20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 56

The team aimed to attend patients within an hour, if the patient was intoxicated or unable to be assessed, the team returned when it was suitable to do so. Staff assessed patients using the SOP and dedicated mental health risk assessment to ensure that patients were not being inappropriately placed within the department, for example within the clinical decisions unit (CDU). Staff we spoke with said they felt much more confident in dealing with patients with mental health needs and that joint working with the mental health liaison team had improved. During our inspection we tracked the records of a patient at risk of self-harm who also had a history of suicide. Staff had documented the risks in relation to their physical and mental health needs. Staff used the sad-persons scoring system to identify ongoing care needs and mental health risk assessment to identify the level of risk. The patient’s capacity and consent had been clearly documented and staff had an escalation plan to support the patient should they deteriorate. This was an improvement from our last inspection where staff did not complete these checks consistently. The needs of patients with a mental health condition were discussed at the staff safety huddles and handovers between shifts to identify any additional needs and mitigate any risks whilst in the department. At the time of our inspection the trust was using agency health care assistants, with specific training in supporting patients with mental health conditions to provide one to one oversight of patients likely to self-harm or at risk of suicide and implemented a new observation form. However, we observed a member of staff supporting a patient at risk due to mental health concerns and not completing the records or detailing any changes in the patient’s condition. The patient was also being cared for in an environment that was not specifically designed for the use of patients with mental health needs. Resources specifically designed for this purpose were not used, staff told us this was because these rooms were already in use by other patients as the department was full. During our inspection, staff within the CED raised concerns that nursing staff compliance levels for emergency paediatric life support (EPLS) training were low. Data supplied by the trust after inspection showed that the percentage of substantive CED nursing staff with an active EPLS course was 50%. The trust had a training plan in place to ensure 100% compliance for all CED nursing staff to achieve compliance by April 2019. In mitigation of the risk, an EPLS trained staff member was on call to answer a bleep system for any emergencies. This risk was also recognised by the trust and featured on the risk register under over all lack of paediatric nurses’ trust wide. Nursing staff achieved 74% compliance with adult basic life support training and 57% compliance with paediatric basic life support, both were below the trust target of 90%. Medical and dental staff achieved 73% compliance with adult basic life support training and 64% compliance with paediatric basic life support, both were below the trust target of 90%. At the time of our inspection we asked the trust to provide assurances regarding the lack of compliance. The trust provided a timetable for additional staff training and reassurances that staff could call for assistance from a paediatric basic life support trained staff member through an on-call bleep system.

Nurse staffing The service did not have enough nursing staff with the right qualifications, skills, training and experience to keep patient's safe from avoidable harm and to provide the right care and treatment. The trust has reported their staffing numbers at March 2018 and at September 2018 for qualified nursing staff in urgent and emergency care. The number of actual staff (WTE) has remained 20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 57 stable between the two points in time, although the trust has increased their planned establishment. For this reason, the fill rate has decreased from 90.7% in March 2018 to 76.0% in September 2018.

As at March 2018 As at September 2018 Actual Planned Actual Planned staff – staff – Fill staff – staff – Fill Site WTE WTE rate WTE WTE rate Norfolk and Norwich University Hospital 209.4 232.5 90.1% 211.7 278.4 76.0% Cromer Hospital 6.3 5.3 118.9% 6.3 8.3 75.7% Trust wide 215.7 237.8 90.7% 217.9 286.7 76.0% (Source: Routine Provider Information Request (RPIR) – Total staffing tab) The trust had been using an electronic system since April 2018, to manage and plan staffing levels in line with patient acuity and measured performance using the Shelford Nursing Care Tool. At the time of our inspection, the department was staffed according to the planned rota. However, there were not always sufficient substantive qualified nurses and health care assistants to staff all areas in the ED to trust’s specified level. The trust did not meet the Royal College of Paediatrics and Child Health (RCPCH) standard of having two registered children’s nurses on every shift. The trusts children’s emergency department standard operating procedure set out the minimum CED staffing levels to mitigate current establishment gaps. This included having one registered children’s nurse (RCN) covering 24 hours per day within the CED, plus a registered nurse with ED paediatric competencies. The trust also provided two health care assistants 24 hours per day, a named nurse with nurse management over sight from main ED and wider paediatrics nurse management teams.

Vacancy rates From September 2017 to August 2018, the trust reported a vacancy rate of 16.4% for qualified nursing staff in urgent and emergency care. The trust does not have a target for vacancy rate. A breakdown by site can be found below. • Norfolk and Norwich University Hospital: 16.6% (Source: Routine Provider Information Request (RPIR) – Vacancy tab) The trusts lack of paediatric nursing staff organisation wide was recognised on their risk register. To mitigate this the trust allocated excess hours from within its occupational therapy team to existing staff within the CED. The department also used bank and agency staff to cover any gaps in working rotas.

Turnover rates From October 2017 to September 2018, the trust reported a turnover rate of 16.3% for qualified nursing staff in urgent and emergency care. This was greater than the trust target of 10.0%. A breakdown by site can be found below. • Norfolk and Norwich University Hospital: 16.8% (Source: Routine Provider Information Request (RPIR) – Turnover tab)

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Sickness rates From September 2017 to August 2018, the trust reported a sickness rate of 4.7% for qualified nursing staff in urgent and emergency care. This was greater than the trust target of 3.5%. A breakdown by site can be found below. • Norfolk and Norwich University Hospital: 4.8% (Source: Routine Provider Information Request (RPIR) – Sickness tab)

Bank and agency staff usage From September 2017 to August 2018, the trust reported that 84,041 of the 765,687 establishment hours were filled by bank staff (11.0%) and 28,630 hours were filled by agency staff (3.7%). There were 42,043 hours (5.5%) that needed to be covered by bank or agency staff but were unfilled. A breakdown of bank and agency usage by staff type is shown below: Total establishment Staff type Bank hours Agency hours Unfilled hours hours Qualified 22,636 (4.5%) 23,264 (4.6%) 33,730 (6.7%) 505,794 Non-qualified 61,405 (23.6%) 5,366 (2.1%) 8,313 (3.2%) 259,894 Total 84,041 (11.0%) 28,630 (3.7%) 42,043 (5.5%) 765,687 (Source: Routine Provider Information Request (RPIR) – Bank and Agency tab)

Medical staffing The service did not have enough medical staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. The trust reported their staffing numbers at March 2018 and at September 2018 for medical and dental staff in urgent and emergency care. The number of actual staff (WTE) has increased over time, although the trust has increased their planned establishment for medical and dental staff in urgent and emergency care. As at September 2018, the trust reported a fill rate of 80.1% for medical and dental staff, an increase from a fill rate of 76.8% reported at March 2018.

As at March 2018 As at September 2018 Actual Planned Actual Planned staff – staff – Fill staff – staff – Fill Site WTE WTE rate WTE WTE rate

Trust wide 76.5 99.7 76.8% 86.7 108.3 80.1% (Source: Routine Provider Information Request (RPIR) – Total staffing tab) The trust was recruiting medical staff to ensure the department had established staff within the medical team. The trust provided an ED consultant in the department from 8am to 12am seven- days per week and ED consultant on-call from 12am to 8am which met the 16 hours consultant cover per day recommended by the Royal College of Emergency Medicine (RCEM). Consultant medical staff managed care throughout the department as needed and one consultant acted as the emergency physician in charge of services. We observed two “Board rounds” where staff discussed key issues in relation to patient’s needs and safety as well as the flow through the department and bed state. Staff used this time as an

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 59 opportunity for more senior medical staff to challenge junior staff on patient’s needs, condition management, and the department situation. The children’s emergency department saw approximately 25,000 patients a year that were less than 17 years of age. The RCEM recommends that emergency departments seeing more than 16,000 children per year should have at least one paediatric emergency consultant. The trust provided 24-hour paediatric consultant cover through an on-call rota.

Vacancy rates From September 2017 to August 2018, the trust reported a vacancy rate of 24.8% for medical and dental staff in urgent and emergency care. The trust does not have a target for vacancy rate. (Source: Routine Provider Information Request (RPIR) – Vacancy tab)

Turnover rates From October 2017 to September 2018, the trust reported a turnover rate of 8.7% for medical and dental staff in urgent and emergency care. This was lower than the trust target of 10.0%. (Source: Routine Provider Information Request (RPIR) – Turnover tab)

Sickness rates From September 2017 to August 2018, the trust reported a sickness rate of 0.7% for medical and dental staff in urgent and emergency care. This was below the trust target of 3.5%. (Source: Routine Provider Information Request (RPIR) – Sickness tab)

Bank and locum staff usage From September 2017 to August 2018, the trust reported that 26,162 of the 225,821 establishment hours were filled by bank staff (11.6%) and 3,674 hours were filled by medical locum staff (1.6%). There were 39,299 hours (17.4%) that needed to be covered by bank or medical locum staff but were unfilled. A breakdown of bank and medical locum usage by unit/ward is shown below: Total Locum establishment Unit/ward Bank hours hours Unfilled hours hours 22,850 3,609 (2.4%) 36,306 (24.2%) 149,776 Accident and emergency (15.3%)

Emergency services 1,234 (1.9%) 0 1168 (1.8%) 65,617 Urgent care centre 2,078 (19.9%) 65 (0.6%) 1,825 (17.5%) 10,429 26,162 Total 3,674 (1.6%) 39,299 (17.4%) 225,821 (11.6%)

(Source: Routine Provider Information Request (RPIR) - Medical agency locum tab)

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From July 2018 to July 2018, the proportion of consultant staff reported to be working at the trust was higher than the England average and the proportion of junior (foundation year 1-2) staff was lower.

Staffing skill mix for the 46 whole time equivalent staff working in urgent and emergency care at Norfolk and Norwich University Hospitals NHS Foundation Trust. This England Trust average Consultant 42% 29% Middle career^ 14% 15% Registrar group~ 28% 32% Junior* 16% 24%

^ Middle Career = At least 3 years at SHO or a higher grade within their chosen specialty ~ Registrar Group = Specialist Registrar (StR) 1-6 * Junior = Foundation Year 1-2 (Source: NHS Digital Workforce Statistics) Staff we spoke with told us the skill mix meant there was a lack of senior clinical decision makers across the ED. RCEM guidance suggests trusts having between 48 and 52 senior clinical decision makers for a similar sized ED. The trust had between 22 and 24 senior clinical decision makers at the time of our inspection. This impacted on patient flow, and patients waiting long periods of time to be seen.

Records Staff kept detailed records of patients care and treatment. Records were clear, up-to-date and easily available to all staff providing care. The service used a blend of paper and electronic patient record systems and staff we spoke with felt confident in using the systems. The trust was aiming to reduce the number of paper based records and increase the use of an electronic system within the ED. We reviewed 24 sets of patient records, including five in relation to children. All the records we reviewed contained details of patients’ presenting conditions, medical history and current medication. Details of their GP and next of kin were also recorded. Risk assessments were fully completed in all the records we reviewed. However, we had concerns that staff observing patients on a one to one basis to monitor their mental health and wellbeing, were not recording their observations of the patient’s condition. This meant that staff may not be recording or sharing changes in the patient’s condition, which could lead to inappropriate interventions taking place, for example longer waiting times, or not following the correct care pathway.

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Information required to deliver care was available in a timely manner for example referring patients for X rays and blood results. Information required for ongoing care was shared appropriately when patients moved between services

Medicines The service prescribed, administered, recorded and stored medicines well. Patients received the right medication at the right dose at the right time. Medicines were checked, managed, stored and disposed of safely. Controlled drugs (medicines that require extra checks and special storage arrangements because of their potential for misuse), were checked by two members of qualified staff twice a day in line with the trust’s medicines policy and were stored correctly in a locked cupboard. Medicines used for emergencies were accessible, checked daily and stored in a tamper proof way. Staff checked refrigeration temperatures in line with trust policy. All medicines we randomly checked were within their expiry dates. Oxygen cylinders were full and within their expiry date. Oral syringes were available for the administration of oral liquid medicines We reviewed ten medication administration records and found that medicines were administered in a timely manner. We noted throughout our inspection that staff administering medication checked the patients name, date of birth and any allergies and patient record to confirm the right medicine was given to the right person at the right time. There were trust protocols, for the administration and supply of certain medicines by nurses under patient group directions (PGDs). PGDs are written instructions for the supply or administration of medicines to groups of patients who may not be individually identified before presentation for treatment. The process for administering medicines under PGDs was safe and effective and nurses received appropriate training for this. Staff had access to several resources for information on medicines, for example on the trust intranet site, policies and procedures and could contact the pharmacy team for further advice. There was a dedicated pharmacist assigned to the ED to support staff with medicines related issues, optimise medicines use and to support the discharge process. Staff we spoke with told us that the pharmacy team were always willing to share advice and give their time to ensure patients were getting the appropriate support. The pharmacy service was available Monday to Friday 8am to 5.45pm, Saturday 9am to 1pm and Sunday 10am to 12pm. In addition, the service offered a seven-day service from 8am to 8am to the ED.

Incidents The service reported safety incidents well, staff recognised incidents and reported them appropriately.

Never Events Never events are serious incidents that are entirely preventable as guidance, or safety recommendations providing strong systemic protective barriers, are available at a national level, and should have been implemented by all healthcare providers.

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From November 2017 to October 2018, the trust reported one incident classified as a never event for urgent and emergency care. The never event related to a retained guidewire (surgical/invasive procedure incident meeting SI criteria). (Source: Strategic Executive Information System (STEIS))

Breakdown of serious incidents reported to STEIS In accordance with the Serious Incident Framework 2015, the trust reported 34 serious incidents (SIs) in urgent and emergency care which met the reporting criteria set by NHS England from November 2017 to October 2018. The breakdown by incident type was as follows: • Commissioning incident meeting SI criteria with 10 (29% of total incidents). • Treatment delay meeting SI criteria with seven (21% of total incidents). • Sub-optimal care of the deteriorating patient meeting SI criteria with four (12% of total incidents). • Pressure ulcer meeting SI criteria with two (6% of total incidents). • Apparent/actual/suspected self-inflicted harm meeting SI criteria with two (6% of total incidents). • Diagnostic incident including delay meeting SI criteria (including failure to act on test results) with two (6% of total incidents). • Abuse/alleged abuse of adult patient by staff with two (6% of total incidents). • Surgical/invasive procedure incident meeting SI criteria with one (3% of total incidents). • Pending review (a category must be selected before incident is closed) with one (3% of total incidents). • Disruptive/ aggressive/ violent behaviour meeting SI criteria with one (3% of total incidents). • Slips/trips/falls meeting SI criteria with one (3% of total incidents). • Medication incident meeting SI criteria with one (3% of total incidents). (Source: Strategic Executive Information System (STEIS)) Incidents were reported using a trust wide electronic system. All staff we spoke with understood their responsibilities to raise concerns and to report safety incidents internally and externally. Medical staff we spoke with told us they had received training and support on incident reporting and using the trust electronic reporting system to report incidents. Staff told us that they had the opportunity on the incident reporting system to request feedback at the time of raising an incident. The trust had recently reported a serious incident in the ED in relation to a patient death. All staff we asked were aware of the incident and told us that mangers had briefed them on the incident detail. However, the department was still experiencing long waits for patients to be assessed and streamed to the appropriate care pathway which increased the risk of a further serious incident in relation to patients waiting to be seen and treated. The trust has implemented a daily multidisciplinary “Serious Incident Review” group which looked at all incidents reported in the previous 24 hours (72 following the weekend) to identify any

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 63 immediate safety actions and allow for a prompt recognition of any themes. A new Chief Executive Officer (CEO) assurance panel had also been established which reviewed all never events and the most complex SIs. The ED clinical leads attended governance meetings and cascaded learning back to the department. Staff told us that key learning from incidents was communicated at team huddles, staff handovers, through the trusts intranet, emails or face to face. We reviewed three serious incident reports and observed that these incidents were investigated by a multidisciplinary team, a full root cause analysis had been undertaken and recommendations identified. Learning was shared with staff through ward huddles, the trusts intranet, ED newsletter and by email. During our inspection we noted a patient had fallen in the RAT area. The patient had been reassessed, additional information shared with social services regarding a care package and the incident reported on the trusts electronic incident system. This demonstrated that staff competed incident reports in a timely way and took appropriate action in line with trust policy. Duty of candour is a regulatory duty that relates to openness and transparency. It requires providers of health and social care services to notify patients or other relevant people of certain notifiable safety incidents and provide reasonable support to that person. The regulation requires staff to be open, transparent, and candid with patients and relatives when things go wrong. Staff we spoke with knew what duty of candour was and told us they would not hesitate in reporting such incidents to a senior manager. We noted in one SI report that the trust held a duty of candour meeting with the patient’s relatives. In another SI, the trust recognised that staff did not communicate in a timely fashion with a patient’s relatives, the trust implemented an action plan to address any shortfalls in communication.

Safety thermometer The service monitored performance and activity to understand risks and provide a clear accurate picture of patient safety. The Safety Thermometer is used to record the prevalence of patient harms and to provide immediate information and analysis for frontline teams to monitor their performance in delivering harm free care. Measurement at the frontline is intended to focus attention on patient harms and their elimination. Data collection takes place one day each month. A suggested date for data collection is given but wards can change this. Data must be submitted within 10 days of the suggested data collection date. Data from the Patient Safety Thermometer showed that the trust reported no new pressure ulcers, one fall with harm and one new urinary tract infection in patients with a catheter from October 2017 to October 2018 within urgent and emergency care. (Source: NHS Digital - Safety Thermometer)

Is the service effective? Evidence-based care and treatment

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The service provided care and treatment that was planned and delivered in line with current evidence based practice. Staff could access local policies, guidelines and procedures on the trust’s intranet. Guidance for staff was also placed next to work stations so staff could quickly find them, for example standards around sepsis and resuscitation. Staff used a range of evidence based risk assessments and tools across the ED. These included Situation, Background, Assessment, Recommendation (SBAR); a technique that can be used to facilitate, prompt and appropriate communication especially amongst doctors and nurses. Other risk assessments included Waterlow pressure risk assessments, SAD and suicide assessment tools for patients with mental health conditions. There were a range of clinical care pathways that aligned with national standards and guidelines. We reviewed four pathways: sepsis, asthma, stroke and fractured neck of femur. All four pathways were multidisciplinary and up to date. Care and treatment for example mental health, pain, feverish children and head injury in adults as was delivered in line with the National Institute of Health and Clinical Excellence (NICE) and Royal College of Emergency Medicine clinical standards (2014). The department ensured care was provided in line with the ‘Clinical Standards for Emergency Departments’ guidelines. Staff followed NICE guidance CG138. This guidance relates to the patient experience in adult NHS services and improving the experience of care for people using adult NHS services. Staff handovers routinely referred to the psychological and emotional needs of patients, as well as their relatives and carers. The department used the “sepsis six-tool” interventions to treat patients and identify those at high risk. We reviewed the record of a patient who had presented as a risk for sepsis, and observed the sepsis bundle and treatment was given within the recommended timeframe of an hour. There was a joint protocol in place between the police and the trust titled Protocol for Fast Track Service for Patients under a Section 136 – Emergency Department to support patients attending the ED. Police can use this section if they think patients have a mental illness, and need 'care or control' in a place of safety which could be a patient’s home, a friend's or relative's home, a hospital, or a police station. The trust had developed advice leaflets for adult and paediatric patients being discharged who were at increased risk of developing sepsis in line with National Institute for Health and Care Excellence (NICE) NG51: Sepsis: recognition, diagnosis and early management (2017). The trusts children’s emergency department standard operating procedure explained the procedures involved in the attendance, treatment and discharge of patients aged 0-15 years of age inclusive, cared for in the CED including those being managed within the resuscitation area of the main department.

Nutrition and hydration Staff assessed patient’s nutrition and hydration needs appropriately. Emergency Department Survey 2016

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In the CQC Emergency Department Survey, the trust scored 7.7 for the question “Were you able to get suitable food or drinks when you were in the emergency department?” This was the same as other trusts. (Source: Emergency Department Survey (October 2016 to March 2017; published October 2017) Staff reviewed patient’s nutrition and hydration needs following the initial triage assessment. If it was safe for patients to eat and drink, staff offered food and drink to meet their needs. We observed staff checking with patients and relatives if they needed food or drink and staff assisted patients who were unable to independently eat and drink. Patients we spoke with told us they had been offered food and drink whilst in the department. One patient told us they had breakfast and staff gave lots of options of what was available to eat and drink. We noted staff assisting one patient that had been in the department for a long time, helping them to eat a sandwich and drink a cup of tea whilst offering reassurance regarding their family coming to visit. The trust also had vending machines for snacks and drinks in the reception areas and patients and relatives could also access restaurants and food kiosks around the hospital site if they were visiting for long periods.

Pain relief Staff assessed, managed and reviewed patient’s pain relief effectively. Emergency Department Survey 2016 In the CQC Emergency Department Survey, the trust scored 6.2 for the question “How many minutes after you requested pain relief medication did it take before you got it?” This was about the same as other trusts. The trust scored 7.8 for the question “Do you think the hospital staff did everything they could to help control your pain?” This was about the same as other trusts. (Source: Emergency Department Survey (October 2016 to March 2017; published October 2017)

Staff monitored patients’ pain using pain assessment tools. They had a visual chart ranging from zero to ten, zero being the least pain with a happy face and ten the worst the pain could be with a very sad face. This was useful to use for children and patients with learning disabilities or for those with impaired communication or cognitive impairment. We noted throughout our inspection that staff routinely asked patients if they were in pain and when they were, staff responded promptly. We spoke with a child within the children’s’ emergency department, they told us that staff asked them about their pain, if they hurt, where the pain was and if they would like some medicine. Nurses were able to administer simple pain relief (paracetamol, anti-inflammatory, local anaesthetic and inhaled gas) under a patient group direction (which permits suitably trained staff to supply prescription-only medicines to groups of patients, without individual prescriptions). We reviewed three sets of paediatric medical records, which revealed staff offered children pain relief within 20 minutes, if clinically required. This demonstrated compliance with the Royal College of Emergency Medicine (RCEM) management of pain in children (July 2013).

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Patient outcomes RCEM Audit: Moderate and acute severe asthma 2016/17 In the 2016/17 Royal College of Emergency Medicine (RCEM) Moderate and acute severe asthma audit, Norfolk and Norwich University Hospital’s emergency department failed to meet any of the national standards. The department was in the upper UK quartile for three standards: • Standard 1a (fundamental): O2 should be given on arrival to maintain sats 94-98%. This department: 92.9%; UK: 19%. • Standard 2a (fundamental): As per RCEM standards, vital signs should be measured and recorded on arrival at the emergency department. This department: 69.1%; UK: 26%. • Standard 5: If not already given before arrival to the emergency department, steroids should be given as soon as possible as follows: o Adults 16 years and over: 40-50mg prednisolone PO or 100mg hydrocortisone IV o Children 6-15 years: 30-40mg prednisolone PO or 4mg/kg hydrocortisone IV o Children 2-5 years: 20mg prednisolone PO or 4mg/kg hydrocortisone IV o Standard 5b (fundamental): within 4 hours (moderate). This department: 56.5%; UK: 28%. The department was in the lower UK quartile for none of the audit standards and was within the middle 50% of results for the remaining four audit standards. • Standard 3 (fundamental): High dose nebulised β2 agonist bronchodilator should be given within 10 minutes of arrival at the emergency department. This department: 35.7%; UK: 25%. • Standard 4 (fundamental): Add nebulised Ipratropium Bromide if there is a poor response to nebulised β2 agonist bronchodilator therapy. This department: 77.8%; UK: 77%. • Standard 5: If not already given before arrival to the emergency department, steroids should be given as soon as possible as follows: o Adults 16 years and over: 40-50mg prednisolone PO or 100mg hydrocortisone IV o Children 6-15 years: 30-40mg prednisolone PO or 4mg/kg hydrocortisone IV o Children 2-5 years: 20mg prednisolone PO or 4mg/kg hydrocortisone IV o Standard 5a (fundamental): within 60 minutes of arrival (acute severe). This department: 26.3%; UK: 19%. • Standard 9 (fundamental): Discharged patients should have oral prednisolone prescribed as follows: o Adults 16 years and over: 40-50mg prednisolone for 5 days o Children 6-15 years: 30-40mg prednisolone for 3 days o Children 2-5 years: 20mg prednisolone for 3 days o This department: 45.5%; UK: 52%. (Source: Royal College of Emergency Medicine)

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RCEM Audit: Consultant sign-off 2016/17 In the 2016/17 Consultant sign-off audit, Norfolk and Norwich University Hospital’s emergency department failed to meet any of the national standards. The department’s results for the four standards were all within the middle 50% of results. Standard 1 (developmental): Consultant reviewed: atraumatic chest pain in patients aged 30 years and over. This department: 18.5%; UK: 11%. Standard 2 (developmental): Consultant reviewed: fever in children under 1 year of age. This department: 20.0%; UK: 8%. Standard 3 (fundamental): Consultant reviewed: patients making an unscheduled return to the emergency department with the same condition within 72 hours of discharge. This department: 15.3%; UK: 12%. Standard 4 (developmental): Consultant reviewed: abdominal pain in patients aged 70 years and over. This department: 18.2%; UK: 10%. (Source: Royal College of Emergency Medicine)

RCEM Audit: Severe sepsis and septic shock 2016/17 In the 2016/17 Severe sepsis and septic shock audit, Norfolk and Norwich University Hospital’s emergency department failed to meet any of the national standards. The department was in the upper UK quartile for three standards: • Standard 1: Respiratory rate, oxygen saturations (SaO2), supplemental oxygen requirement, temperature, blood pressure, heart rate, level of consciousness (AVPU or GCS) and capillary blood glucose recorded on arrival. This department: 96.0%; UK: 69.1%. • Standard 2: Review by a senior (ST4+ or equivalent) emergency department medic or involvement of critical care medic (including the outreach team or equivalent) before leaving the emergency department. This department: 98.0%; UK: 64.6%. • Standard 3: O2 was initiated to maintain SaO2>94% (unless there is a documented reason not to) within one hour of arrival. This department: 59.2%; UK: 30.4%. The department was in the lower UK quartile for none of the audit standards. The department’s results for the remaining five standards were all within the middle 50% of results: • Standard 4: Serum lactate measured within one hour of arrival. This department: 66.0%; UK: 60.0%. • Standard 5: Blood cultures obtained within one hour of arrival. This department: 52.0%; UK: 44.9%. • Standard 6: Fluids – first intravenous crystalloid fluid bolus (up to 30 mL/Kg) given within one hour of arrival. This department: 50.0%; UK: 43.2%. • Standard 7: Antibiotics administered: Within one hour of arrival. This department: 44.0%; UK: 44.4%. • Standard 8: Urine output measurement/fluid balance chart instituted within four hours of arrival. This department: 24.5%; UK: 18.4%.

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(Source: Royal College of Emergency Medicine)

The trust confirmed that there have been no further RCEM audits in relation to moderate and acute severe asthma, consultant sign-off, or severe sepsis and septic shock since 2016/17. The trust stated that RCEM audit topics change each audit year and therefore these were not on the following years audit schedule for the trust to participate in.

Trauma Audit and Research Network (TARN) Norfolk and Norwich University Hospital The table below summarises Norfolk and Norwich University Hospital’s performance in the 2016 Trauma Audit and Research Network audit. The TARN audit captures any patient who is admitted to a nonmedical ward or transferred out to another hospital (e.g. for specialist care) whose initial complaint was trauma (including shootings, stabbings, falls, vehicle or sporting accidents, fires or assaults). Metrics Hospital Meets national Audit’s Rating (Audit measures) performance standard? Case Ascertainment (Proportion of eligible cases reported to TARN compared against Hospital 100+% Good ✓ Episode Statistics data) Crude median time from arrival to CT scan of the head for patients with traumatic brain injury ✓ Takes longer (Prompt diagnosis of the severity of 52 minutes than the TARN traumatic brain injury from a CT scan aggregate *Nice guideline of is critical to allowing appropriate treatment which minimises further 60 minutes brain injury.) Crude proportion of eligible patients receiving Tranexamic Acid within 3 hours of injury Lower than the No national (Prompt administration of tranexamic 52.9% TARN standard acid has been shown to significantly aggregate reduce the risk of death when given to trauma patients who are bleeding) Crude proportion of patients with severe open lower limb fracture receiving appropriately timed Lower than the surgery (Outcomes for this serious 9.1% TARN type of injury are optimised when  aggregate surgery is carried out in a timely fashion by appropriately trained specialists.) Risk-adjusted in-hospital survival rate following injury (This metric uses case-mix 0.2 additional Similar to adjustment to ensure that hospitals survivors expected ✓ dealing with sicker patients are compared fairly against those with a less complex case mix.)

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Note regarding case ascertainment: Calculated using number of patients reported to the audit as a percentage of the number of cases within the audit period according to HES. This can be larger than 100% if more patients are reported to the audit than identified in HES. (Source: TARN) The trust provided updated information on their performance from the trauma unit (TU) dashboard prepared by TARN and published 17 January 2019. This dashboard reports on the quality of the data the trust submits as well as how it performs on evidence based measures. In terms of data quality, it shows that the trust performs as expected in terms of the quality of data they submit to TARN but they perform much worse than other trusts for percentage of all TARN eligible patients having their data submitted to the audit (36.1% compared to a national mean of 76.7%). Of the eleven-evidence based measure reported on in the dashboard, the trust performs much better than expected for one: • TU 07b - Rapid access to specialist MTC care - patients transferred to MTC within 2 days of referral request The trust performs as expected for five metrics: • TU 04 - TUs administer Tranexamic Acid within three hours of incident to patients that receive blood products within six hours of incident • TU 05a - TUs deliver Consultant led trauma teams within 30 minutes with Pre-Alert and/or Trauma Team and ISS > 15 patients • TU 05b - TUs deliver Consultant led trauma teams within 30 minutes for patients with ISS > 15 • TU 07a - Rapid access to specialist MTC care - patients transferred to MTC within 12 hours of referral request • TU 08 - Proportion of patients with GCS <9 with definitive airway management within 30 minutes of arrival in ED The trust performs worse than expected for one metric: • TU 03 - Proportion of patients meeting NICE head injury guidelines that receive CT scan within 60 minutes of arrival at TU The trust performs much worse compared to other trusts for four metrics: • TU 06a - TUs deliver grade STR 3 or above led trauma teams on arrival for Pre-Alert and/or Trauma Team patients • TU 06b - TUs deliver grade STR 3 or above led trauma teams on arrival • TU 09 - Proportion of directly admitted patients receiving CT scan within 60 minutes of arrival at TU • TU 10 - Proportion of patients with an ISS of more than 8 that have a rehabilitation prescription completed (Source: Data Request – DR26)

Unplanned re-attendance rate within seven days

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From October 2017 to September 2018, the trust’s unplanned re-attendance rate to A&E within seven days was consistently worse than the national standard of 5% and better than the England average. In the most recent month, September 2018, the trust’s unplanned re-attendance rate was 6.0% compared to an England average of 8.5%.

Unplanned re-attendance rate within seven days - Norfolk and Norwich University Hospitals NHS Foundation Trust

(Source: NHS Digital - A&E quality indicators)

Competent staff Not all managers appraised staff’s work performance or held supervision meetings.

Appraisal rates As of January 2019, the trust reported the following appraisal rates for the staff groups working in urgent and emergency care.

Appraisals Completed Appraisal Trust Met Staff group required appraisals rate target (Yes/No)

Medical & Dental staff 45 42 93% 80% Yes Support to doctors and nursing staff 126 85 67% 80% No Qualified nursing & health visiting 185 107 58% 80% No staff (Qualified nurses)

Medical and dental staff exceeded the trust target appraisal rate of 80% but qualified nurses and support to doctors and nursing staff groups did not. (Source: Data Request – DR09)

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Medical staff told us they had regular supervision and appraisals that included 360-degree feedback from colleagues. (360-degree feedback is a process through which feedback from an employee's subordinates, colleagues, and supervisor, as well as a self-evaluation by the employee themselves is gathered). Nursing and health care assistants, we spoke with told us they received appraisals and that these were an opportunity to discuss their future development and any training or mentoring needs. Staff had the skills, knowledge and experience to identify and manage issues arising from patients with mental health conditions and this was an improvement from our last inspection. The trust had qualified nurses specifically to support patients with learning disability, autism and dementia. Staff we spoke with throughout our inspection were clear on their roles in relation to supporting patients who may need additional support. The trust had arrangements in place to make sure local healthcare providers were informed in cases where a staff member was suspended from duty and dealing with allegations against staff. The psychiatric liaison team worked for the trust as part of a service level agreement with another local NHS trust. The staff had the skills, knowledge and experience to work with patients with a wide range of mental health needs. We observed staff sensitively managing difficult behaviours displayed by patients and using their skills to deescalate situations where aggression was likely to occur.

Multidisciplinary working Staff of different kinds worked together as a team to benefit patients. Throughout our inspection we noted multidisciplinary team working (MDT) across the ED. We spoke with occupational therapy staff, who were very positive about their relationships with the ED teams and explained how they worked together to improve patient outcomes and how they used links with community based staff and resources to coordinate patient care and where possible speed up safe discharge. The ED had major incident continuity plans that used MDT working and drew together specialism from across the trust to deal with major incidents appropriately. The ED had strong links and relationships with the psychiatric health liaison team, who provided support to ED and the clinical decisions unit. The teams had good working relationships and communicated together regularly to plan patient care and treatment. The team was based outside of the department, they attend when patients were referred to them.

Seven-day services Key services were available seven days a week to support patient care. The ED, OPED, CED and the clinical decisions unit (CDU) were open 24 hours a day, seven days a week. Patients arrived by ambulance, on foot or as a referral from their general practitioner. The ED had 24-hour access to pathology, and diagnostic tests such as, blood tests, x-rays, computed tomography (CT) scans and magnetic resonance imaging (MRI) scans. The chaplaincy service was available 24 hours a day seven day a week.

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Health promotion Staff were proactive in supporting patients to live healthier lives. The trust was a non-smoking organisation, and helped to promote the health benefits of not smoking through leaflets and posters placed around the hospital. Staff used the trust intranet for a wide range of resources and could signpost patients to other organisations for alcohol misuse, smoking cessation, sexual health and weight loss amongst others. All the ED areas held leaflets that offered patients advice and guidance on issues such as diabetes, promoting healthy lifestyles and dealing with minor injuries.

Consent, Mental Capacity Act and Deprivation of Liberty Safeguards Staff obtained consent to care and treatment in line with legislation.

Mental Capacity Act and Deprivation of Liberty training completion The trust set a target of 90% for completion of Mental Capacity Act (MCA) and Deprivation of Liberty training. Trust level A breakdown of compliance for Mental Capacity Act (MCA) and Deprivation of Liberty Safeguarding (DoLS) courses at September 2018 for qualified nursing staff in urgent and emergency care is shown below: Number of Number of eligible staff trained staff Completion Trust Met Name of course (YTD) (YTD) rate Target (Yes/No) Mental Capacity Act Level 1 193 239 81% 90% No Deprivation of Liberty Safeguards 190 239 79% 90% No

Qualified nursing staff did not meet the trust training target for either of the training modules relating to the Mental Capacity Act (MCA) or Deprivation of Liberty (DoLS). A breakdown of compliance for Mental Capacity Act (MCA) and Deprivation of Liberty Safeguarding (DoLS) courses at September 2018 for medical and dental staff in urgent and emergency care is shown below: Number of Number of eligible staff trained staff Completion Trust Met Name of course (YTD) (YTD) rate Target (Yes/No) Deprivation of Liberty Safeguards 52 64 81% 90% No Mental Capacity Act Level 1 51 63 81% 90% No

Medical staff did not meet the trust training target for either of the training modules relating to the Mental Capacity Act (MCA) or Deprivation of Liberty (DoLS). (Source: Routine Provider Information Request (RPIR) – Training tab)

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Norfolk and Norwich University Hospital A breakdown of compliance for Mental Capacity Act (MCA) and Deprivation of Liberty Safeguarding (DoLS) courses at September 2018 for qualified nursing staff in urgent and emergency care at Norfolk and Norwich University Hospital is shown below: Number of Number of eligible staff trained staff Completion Trust Met Name of course (YTD) (YTD) rate Target (Yes/No) Mental Capacity Act Level 1 186 232 80% 90% No Deprivation of Liberty Safeguards 183 232 79% 90% No

Qualified nursing staff did not meet the trust training target for either of the training modules relating to the Mental Capacity Act (MCA) or Deprivation of Liberty (DoLS). Note: The trust was unable to provide site level training data for medical and dental staff working in urgent and emergency care. (Source: Routine Provider Information Request (RPIR) – Training tab) The trust provided updated information for MCA, DoLS and dementia basic awareness training courses for qualified nursing staff in urgent and emergency at Norfolk and Norwich University Hospital as of January 2019.

As of January 2019

Training module name Staff Eligible Completion Trust Met trained staff rate target (Yes/No)

Dementia Basic Awareness 230 238 97% 90% Yes Mental Capacity Act (MCA) 212 239 89% 90% No Deprivation of Liberty Safeguards (DoLS) 211 239 88% 90% No

The 90% target was met for the dementia basic awareness training module with the MCA and DoLS modules both close to the target. The trust provided updated information for MCA, DoLS and dementia basic awareness training courses for medical and dental staff in urgent and emergency at Norfolk and Norwich University Hospital as of January 2019.

As of January 2019

Training module name Staff Eligible Completion Trust Met trained staff rate target (Yes/No)

Deprivation of Liberty Safeguards (DoLS) 53 63 84% 90% No Mental Capacity Act (MCA) 52 62 84% 90% No Dementia Basic Awareness 49 70 70% 90% No

The 90% target was not met for any of the three training modules. (Source: Data Request – DR10)

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Qualified nursing staff met the trust training target for both training modules relating to the Mental Capacity Act (MCA) or Deprivation of Liberty (DoLS). Note: The trust was unable to provide site level training data for medical and dental staff working in urgent and emergency care. (Source: Routine Provider Information Request (RPIR) – Training tab) Although the trust had not achieved the 90% compliance target for staff training in relation to the Mental Capacity Act (2005) (MCA) and Deprivation of Liberty Safeguards (2009) (DoLS) all staff we spoke with understood their roles and responsibilities. This was an improvement from our last inspection. The trust had an up to date and version controlled policy for MCA and DoLS and staff knew to access this on the trusts intranet. The trust introduced a credit card sized MCA and DoLS information card. We noted staff had these within their ID tags and staff told us these had been helpful as a quick reference guide. Staff understood their roles and responsibilities under the Children’s Act (2004), the Mental Health Act (MHA) (1983) and knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care. We noted that staff completed MCA assessments and MHA assessments for patients lacking capacity within the ED, this was an improvement on our last inspection. We also observed staff routinely asking patients for consent prior to care and treatment. Staff we spoke with in the children’s emergency department (CED) understood the importance of the law relating to Fraser guidelines and Gillick competencies when caring for a patient under the age of 16. The Fraser guidelines refer specifically to consent for sexual health services, and are an additional guideline to the Gillick competency framework that relates to consent for any healthcare intervention. There were no examples to review during our inspection.

Is the service caring? Compassionate care Staff treated patients with compassion, dignity and respect during interactions.

Friends and Family test performance The trust’s urgent and emergency care Friends and Family Test performance (% recommended) was better than the England average from October 2017 to September 2018. The trust’s performance ranged from 91.0% to 98.7% and the England average ranged from 84.3% to 87.7%. In September 2018, the trust’s performance was 95.1%, compared to the England average of 86.5%.

A&E Friends and Family Test performance - Norfolk and Norwich University Hospitals NHS Foundation Trust

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(Source: NHS England Friends and Family Test) We observed examples of staff responding with kindness when patients needed help and support, even during exceptionally busy periods. Staff offered reassurance to patients who were in pain or frightened and we observed staff promoting patients’ needs. Reception staff were welcoming, kind and offered patients clear guidance on waiting times and who would be assessing them. All patients we spoke with told us staff were very helpful and caring and they were treated respectfully. Staff recognised patient’s individual needs and we noted on the children’s emergency department (CED) that children were treated with kindness and patience. We spoke with a child who told us that staff had been kind and made them feel better. We discreetly observed calm, kind conversations between staff, children and their parents during assessments and treatments. Staff offered care that was kind and promoted dignity. Where patients were receiving care and treatment in cubicles we observed staff closing curtains to protect people’s privacy and routinely asking for consent prior to undertaking examinations or treatment. Staff in the emergency department (ED) worked with patients who presented with behaviours that staff might find challenging. We observed them to be caring when a patient who was confused and shouting aggressively at the staff. However, on two occasions staff did not use the correct environment for a patient and the patient received care in an environment that did not meet their individual needs or promote their privacy. One patient we spoke with on the older peoples’ emergency department said, “Perfect care, very happy”. Another patient told us the physiotherapy staff had been “Very kind, offered them food and a drink, very attentive and friendly”.

Emotional support Patients were given support to cope emotionally with their care, treatment or condition.

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Staff considered the mental health of patients was as important as their physical needs. We routinely observed staff asking patients and their relatives if they needed any additional support. We spoke with a patient who told us, “I feel safe and looked after well, the nurses checked my pain and they were kind”. During our inspection we talked with a trust chaplain who visited the department to offer emotional support for patients and their families, as well as supporting families though trauma and loss of a loved one. The chaplaincy team were available 24 hours a day throughout the year to provide emotional support at times of need and sign post patients and families to other support and caring groups.

Understanding and involvement of patients and those close to them Emergency Department Survey 2016 The trust scored about the same as other trusts for all 24 of the Emergency Department Survey questions relevant to the caring domain. Question Trust 2016 2016 RAG 3.3 About the Q10. Were you told how long you would have to wait same as to be examined? other trusts 8.6 About the Q12. Did you have enough time to discuss your same as health or medical problem with the doctor or nurse? other trusts 8.3 About the Q13. While you were in the emergency department, same as did a doctor or nurse explain your condition and other treatment in a way you could understand? trusts 8.9 About the Q14. Did the doctors and nurses listen to what you same as had to say? other trusts 9.0 About the Q16. Did you have confidence and trust in the same as doctors and nurses examining and treating you? other trusts 9.4 About the Q17. Did doctors or nurses talk to each other about same as you as if you weren't there? other trusts 7.9 About the Q18. If your family or someone else close to you same as wanted to talk to a doctor, did they have enough other opportunity to do so? trusts 8.6 About the Q19. While you were in the emergency department, same as how much information about your condition or other treatment was given to you? trusts 8.0 About the Q21. If you needed attention, were you able to get a same as member of medical or nursing staff to help you? other 20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 77

Question Trust 2016 2016 RAG trusts Q22. Sometimes in a hospital, a member of staff will 9.1 About the say one thing and another will say something quite same as different. Did this happen to you in the emergency other department? trusts 8.3 About the Q23. Were you involved as much as you wanted to same as be in decisions about your care and treatment? other trusts 9.3 About the Q44. Overall, did you feel you were treated with same as respect and dignity while you were in the emergency other department? trusts 7.5 About the Q15. If you had any anxieties or fears about your same as condition or treatment, did a doctor or nurse discuss other them with you? trusts 7.1 About the Q24. If you were feeling distressed while you were in same as the emergency department, did a member of staff other help to reassure you? trusts 8.7 About the Q26. Did a member of staff explain why you needed same as these test(s) in a way you could understand? other trusts 7.9 About the Q27. Before you left the emergency department, did same as you get the results of your tests? other trusts 8.9 About the Q28. Did a member of staff explain the results of the same as tests in a way you could understand? other trusts 9.1 About the Q38. Did a member of staff explain the purpose of same as the medications you were to take at home in a way other you could understand? trusts 4.9 About the Q39. Did a member of staff tell you about medication same as side effects to watch out for? other trusts 6.2 About the Q40. Did a member of staff tell you when you could same as resume your usual activities, such as when to go other back to work or drive a car? trusts 5.3 About the Q41. Did hospital staff take your family or home same as situation into account when you were leaving the other emergency department? trusts 6.0 About the Q42. Did a member of staff tell you about what same as danger signals regarding your illness or treatment to other watch for after you went home? trusts Q43. Did hospital staff tell you who to contact if you 8.0 About the

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Question Trust 2016 2016 RAG were worried about your condition or treatment after same as you left the emergency department? other trusts 8.2 About the same as Q45. Overall... (please circle a number) other trusts

(Source: Emergency Department Survey (October 2016 to March 2017; published October 2017)

Patients, carers and those close to them were encouraged to be active partners in their care. Throughout our inspection, we observed staff introducing themselves and their role to patients they were caring for within the ED. We heard staff explaining care and treatment plans in a way that people could understand and engaging with family members. On the older peoples’ emergency department, we observed staff explaining a patient’s treatment plan to their close relative and discussing their next steps when being moved to a ward area. Staff gave time for the relative to ask questions and gave reassurance whilst explaining what would happen next and ensuring they had clear involvement in the care planning process. Patients and their relatives told us staff listened to and involved them in their care and treatment. We spoke with a patient who told us they received clear guidance on how to look after the injury and how to seek further guidance should their condition worsened. The chaplaincy team worked closely with the department and could also offer ongoing support for families of staff who wanted to discuss any unresolved concerns or issues. We spoke with one patient who told us they knew their plan of care, and staff had been very kind to them and explained why they had taken their blood and felt safe. Another patient told us they had been seen by a physiotherapist, who explained what the plan of care would be. Overnight the staff had been very attentive and carried out observations, explaining what was happening and why. We spoke to the relative of an elderly gentleman, who told us they had been fully involved in their relatives care and treatment, and they felt their relative would be looked after well.

Is the service responsive? Service delivery to meet the needs of local people Services were tailored to meet individual needs and person-centred pathways involved other providers. Information about the needs of the local population was used to inform service planning and delivery. The trust was involved with local commissioners and other health care providers working together to provide urgent and emergency care to patients. Since our last inspection the trust had increased the size and capacity within its emergency department (ED) based on the needs of the local population. The older peoples’ emergency

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 79 department (OPED), rapid assessment and treatment (RAT), urgent and emergency care centre (UCC) and children’s emergency department (CED) had significantly increased the size of the environment and responded to the challenges of the increased number of patient attendances. The OPED was specifically supporting patients over the age of 80 years, as the trust had recognised this was an area of growth and dedicated staff towards meeting the needs of this patient cohort. Staff liaised closely with other teams within the hospital and older peoples’ services, as well as local social care services and agencies to support discharges and sign post patients and families to the correct resources. All ambulatory patients arrived at the front door of the ED and were triaged by a nurse who ensured they were directed to the area of ED that met their needs. This ensured that patients moved to appropriate areas and were aware of where they needed to go to be seen. The environment of the ED was suitable to meet the needs of patients with a physical and/or learning disability. Staff we spoke with told us they would request the learning disability nurse to visit if they needed support with a patient. Throughout the ED there was adequate seating available for patients and patients had access to vending machines for food and drink. In the CED, children had a wide range of play resources including a large robot TV, books and toys.

Meeting people’s individual needs The service demonstrated a pro-active approach to understand the needs of the different patient groups to deliver care to meet those needs, which is accessible and promotes equality. Emergency Department Survey 2016 The trust scored about the same as other trusts for all three of the Emergency Department Survey questions relevant to the responsive domain. Question – Responsive Score RAG Q7. Were you given enough privacy when discussing your 7.5 About the same as condition with the receptionist? other trusts Q11. Overall, how long did your visit to the emergency 7.1 About the same as department last? other trusts Q20. Were you given enough privacy when being 9.3 About the same as examined or treated? other trusts (Source: Emergency Department Survey (October 2016 to March 2017; published October 2017) Staff we spoke with told us that translators were offered to patients whose first language was not English. The trust referred patients with drug and alcohol dependencies to a service in the community. Information about the community support service was available for patients. We observed staff sharing this information with patients to enable patients. There were processes in place to support patients with a learning disability. The trust had an electronic patient alert system (EPAS) flagging and alert system for patients with learning disabilities and or autism spectrum conditions. This alerted the learning disability liaison nursing team whenever somebody with one of those alerts is admitted. Staff told us they could request the

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 80 support of the learning disability liaison nursing team if required. The trust has three learning disability specialist nurses, two who work full time and one-part time. Staff we spoke with were aware of how to support patients living with dementia. Nursing staff achieved 97% compliance with dementia basic awareness training, above the trusts compliance target of 90%. Medical and dental staff achieved 70% compliance with dementia basic awareness training. The staff used a flag on the EPAS for all patients coded with a dementia diagnosis. The flag was a blue forget-me -not flower and automatically showed on ward view screens as well as the EPAS. The trusts dementia care clinical nurse specialist assessed dementia care needs of patients referred the dementia team and worked with the dementia support workers. Patients with a diagnosis of dementia also had a booklet titled 'This is Me' completed to assist person centred care. Staff knew where the living with dementia resources were located and the trust had implemented its older persons emergency department (OPED) to meet the needs of this patient cohort. The living with dementia resources included various aids designed to reduce anxiety for a patient living with dementia. The psychiatric health liaison team provided support to ED and the clinical decisions unit. The teams had good working relationships and communicated together regularly to plan patient care and treatment. The team was based outside of the department, they attend when patients were referred to them. Since our last inspection the trust had implemented specific standard operating procedures and risk assessment to help staff support patients with mental health needs and ensure their welfare and safety was promoted, this was an improvement on our last inspection. The children’s area had a variety of age appropriate toys and books within its dedicated waiting area and a large robot TV to attract children’s attention. The ED offered a wide range of information booklets throughout all its departments, designed to support patients to self-manage conditions and minor injuries, for example ankle injury, sprain and strain.

Access and flow Patients did not always access services to receive the right care at the right time. During times of high demand access to care was not managed by staff to consider patients with urgent needs.

Median time from arrival to treatment (all patients) The Royal College of Emergency Medicine recommends that the time patients should wait from time of arrival to receiving treatment should be no more than one hour. The trust met the standard for no months in the 12-month period from October 2017 to September 2018. From October 2017 to September 2018 performance against this standard was worse than the England average. The trust had longest waits in the winter months. February 2018 had the longest median wait time, which was 127 minutes compared to the England average of 61 minutes. In September 2018 (most recent month), the median time to treatment was 87 minutes compared to the England average of 61 minutes.

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Median time from arrival to treatment from October 2017 to September 2018 at Norfolk and Norwich University Hospitals NHS Foundation Trust

(Source: NHS Digital - A&E quality indicators)

Percentage of patients admitted, transferred or discharged within four hours (all emergency department types) The Department of Health’s standard for emergency departments is that 95% of patients should be admitted, transferred or discharged within four hours of arrival in the emergency department. From November 2017 to October 2018 the trust failed to meet the standard in every month and performed worse than the England average. In October 2018, 84% of patients at the trust were admitted, transferred or discharged within four hours of arrival in the emergency department. This was lower than the England average of 89%.

Four-hour target performance - Norfolk and Norwich University Hospitals NHS Foundation Trust

(Source: NHS England - A&E Waiting times) Performance against the four-hour standard was 66.9% during our inspection, but we noted this drop to 43% and 52% on occasion. Staff we spoke with explained that flow throughout the trust was an issue and getting specialities to assess patients within the ED was sometimes difficult and not within their respective professional standard of seeing a patient within 30 minutes.

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Following our inspection, we asked the trust if they had closed the ED at any time. The trust told us they had not closed the ED at any point in the six months prior to our inspection. Ambulance diverts are at the discretion of the ambulance service and would be recorded by them; the trust would not necessarily know this was being done.

Percentage of patients waiting more than four hours from the decision to admit until being admitted From November 2017 to October 2018 the trust’s monthly percentage of patients waiting more than four hours from the decision to admit until being admitted was worse than the England average.

Percentage of patients waiting more than four hours from the decision to admit until being admitted - Norfolk and Norwich University Hospitals NHS Foundation Trust

(Source: NHS England - A&E SitReps)

Number of patients waiting more than 12 hours from the decision to admit until being admitted Over the 12 months from November 2017 to October 2018, three patients waited more than 12 hours from the decision to admit until being admitted. The months when this occurred were January, July and October 2018. During our inspection we noted that staff monitored patient waiting times and that no patients waited longer than 12 hours within the ED. (Source: NHS England - A&E Waiting times)

Percentage of patients that left the trust’s urgent and emergency care services before being seen for treatment From December 2017 to September 2018, the trust reported that no patients left the trust’s urgent and emergency care services before being seen for treatment. This suggests that there may be an issue with reporting of this metric at the trust.

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From October 2017 to September 2018, the England average performance against this metric ranged from 1.9% to 3.5%. (Source: NHS Digital - A&E quality indicators)

Median total time in A&E per patient (all patients) From October 2017 to September 2018 the trust’s monthly median total time in A&E for all patients was consistently higher than the England average. In September 2018, the trust’s monthly median total time in A&E for all patients was 177 minutes compared to the England average of 154 minutes.

Median total time in A&E per patient - Norfolk and Norwich University Hospitals NHS Foundation Trust

(Source: NHS Digital - A&E quality indicators)

Since our last inspection the trust had introduced a new role within the ED, known as the ED flow coordinator. This role was specifically to address the flow and access to services for patients within the ED. The trust had also implemented a winter management team, to specifically deal with increased demand on the department throughout the winter months. There was a dedicated entrance for ambulance and air ambulance arrivals which led to the resuscitation and rapid assessment and treatment (RAT) areas which enabled critically ill patients to be triaged and transferred to the correct area in a timely manner. Ambulant patients accessed the ED through the main ED reception. They were greeted by a qualified nurse who completed a triage assessment and pain score; they then directed the patient to the appropriate treatment pathway within the ED, ambulatory care unit (ACU), ambulatory emergency care unit (AEC), clinical decisions unit (CDU) and UCC. Staff had access to care pathways including supporting patients with a fractured neck of femur, stroke or sepsis. The pathways were based on best practice guidance.

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The trust used AEC to support care pathways that avoided admission into the wider hospital. Data supplied by the trust post inspection showed that in December 2018, there were 11,454 ED attendances, with 502 new AEC attendances. Children were immediately directed to the CED on arrival. All patients were triaged on arrival and transferred to the area best suited to provide treatment. We reviewed the notes of two children in relation to CEWS (Children’s Early Warning Score), staff triaged the children within fifteen minutes, complying with the standards for children, and young people in emergency care settings set by the Royal College of Paediatrics and Child Health (RCPCH 2012). At times of increased patient demand, the main ED did not use escalation processes effectively to meet patient needs. Despite the increase in the size of the physical environment, the lack of clinical decision makers and the management of the flow through the department affected the ability to stream patients effectively to receive appropriate care and treatment. Staff described coordination between medical wards and the ED as cumbersome, with staff having to rely on telephone systems and physically checking with colleagues if beds were available on wards to aid patient flow through the department. Staff gave numerous anecdotal accounts of having to go to medical wards and physically check of beds were available. Staff gave examples of having to wait long periods for other specialities to come to the ED and assess patients, with specialties not meeting the professional standard of assessing the patient within 30 minutes. This led to patient waiting longer to be seen and flow being restricted between the ED and other ward areas. During our unannounced inspection on 14 February 2019, the trust had taken the decision to ensure all request for specialities to review patients came through centrally through the acute admissions unit, staff we spoke with told us this had only just changed. Initial feedback from staff regrading this change was positive. The rapid assessment and treatment process (RAT) was not fully embedded. We noted that patient arriving by ambulance were routinely met by triage staff and recorded onto the hospitals arrival system within five minutes in line with Royal College of Emergency Medicine (RCEM) guidance. However, patients then routinely experienced extended periods of waiting to be seen by a clinician. At the time of our inspection many patients were waiting between four to six hours to be seen and decision made on their care pathway which led to longer stays in the emergency department. At the time of our inspection we noted at one point thirteen ambulances waiting with patients on board, the RAT was full and all other areas of the ED were at full capacity. Staff did their best to move patients around the department, and establish flow. However, the system of escalation was not effective in reducing the pressure within the ED or identifying those patients at increased risk of deterioration. We spoke with ambulance staff who told us that during times of high demand there was often a delay in getting patients off ambulances and long waits to be seen. Ambulance staff told us it was not routine for a clinician or any one from the trust to check on a patient’s condition on an ambulance, but this did happen if they escalated their concerns and if a clinician was available. Hospital ambulance liaison officers (HALOs) employed by a local NHS ambulance trust, who worked alongside the ED team to support patient flow. At the time of our inspection we highlighted our concerns in relation to flow and staff supporting and identifying those patients at risk of deterioration. Following our inspection, we raised our concerns to the trust regarding this risk and they implemented standard operating procedures to increase the oversight of patients and identify

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 85 patients most likely to deteriorate. We carried out an unannounced follow up inspection the ED on 14 February 2019 and staff gave mixed feedback on the new procedures. Generally, staff told us that they had not used the new system, or had training in its operation and that it very much depended who was on duty as to whether the system would be used.

Learning from complaints and concerns The service managed and responded to concerns and complaints.

Summary of complaints From October 2017 to October 2018 there were 124 complaints about urgent and emergency care. The trust took an average of 25 days to investigate and close complaints, and 49.4% of the complaints were closed within 25 days. This is not in line with their complaints policy, which states that more than 50% of complaints should be closed within 25 days. A breakdown of complaints by site and subject can be found below.

Norfolk and Norwich University Hospital Number of Percentage of Core service complaints total complaints Clinical Treatment - A&E 63 51.6% Communications 20 16.4% Values and Behaviours (Staff) 7 5.7% Patient Care including Nutrition/Hydration 6 4.9% Privacy, Dignity and Wellbeing 5 4.1% Waiting Times 4 3.3% Admission, Discharge and Transfers 3 2.5% Facilities 3 2.5% Other 2 1.6% Clinical Treatment - General Medical 2 1.6% Prescribing Errors 2 1.6% Appointments including delays and cancellations 2 1.6% Transport (Ambulances Only) 1 0.8% Clinical Treatment - Radiology 1 0.8% Clinical Treatment - Paediatrics 1 0.8% Total 122 100.0% (Source: Routine Provider Information Request (RPIR) – Complaints tab)

Number of compliments made to the trust From October 2017 to September 2018 there were 151 compliments within urgent and emergency care. A breakdown by site and ward can be found below.

Norfolk and Norwich University Hospital

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Percentage of Number of Ward name/area total compliments compliments Accident and Emergency 103 85.1% AMU K 8 6.6% Children's ED 7 AMU H 6 5.0% Older People’s Emergency Department 4 3.3% Total 128 100.0% (Source: Routine Provider Information Request (RPIR) – Compliments tab) The trust had a complaints policy which ensured that systems and processes were in place to enable patients and relatives to make a complaint. Information about how to complain was available across the emergency departments we visited. Staff understood their responsibilities to support people to complain and we noted guidance in relation to the patient advice and liaison service (PALS) on notice boards and placed around the various ED areas. All staff we spoke with were aware of the complaints process and where to direct patients and relatives to if they could not resolve the complaint within the department. Managers we spoke to told us if a formal complaint was made they were managed in confidence, with a regular update for the complainant. Staff received feedback from any complaints at ward huddles and team meetings, learning was identified and actions recognised and implemented.

Is the service well-led? Leadership There was a lack of leadership within the department, staff roles and responsibilities were not coordinated effectively to manage patient care. At the time of our inspection the trust had implemented a new leadership structure into the emergency department (ED) called the “Winter Team” to deal with the expected increase in patient flow throughout the winter months. This was a triumvirate team consisting of the trusts medical lead, divisional nurse director and operations director, who oversaw the operations manager, senior matrons and clinical service director. Staff we spoke with saw senior leaders as inhibiters not as leaders, often implementing change without thinking the changes through or understanding the impact. Staff routinely described the department as having too many managers and no leadership. We noted throughout our inspection that staff often lacked coordination, they didn’t know who oversaw the department or who to call for support when needed. Staff told us this was a cultural norm, new medical staff often didn’t understand the department well, or know where to go. During our inspection we observed staff were often clumped together, and seeking guidance on what to do next from other staff members, lacking clear direction or the ability to make decisions on patient care.

Vision and strategy There was a trust wide vision for what it wanted to achieve which it developed with staff, patients, and local community groups. There was no specific vison or plan for the emergency department. 20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 87

The trust vision was to provide every patient with the care we want for those we love the most. To underpin this the trust had a five-year development strategy, with four core goals. Goal one, to be a provider of high quality health and care services to our local population. Goal two, to be the centre for complex and specialist medicine for Norfolk and the Anglia region. Goal three, to be a centre of excellence for research, education and staff development. Goal four, to be a leader in the redesign and delivery of health and social care services in Norfolk. The trusts had five core values aimed to support the vision and guide the behaviour of everything they did. The values included, being People-focused, we look after the needs of our patients, carers and colleagues, to provide a safe and caring experience for all. Respect, we act with care, compassion and kindness and value others’ diverse needs. Integrity, we take an honest, open and ethical approach to everything we do. Dedication, we work as one team and support each other to maintain the highest professional standards. The trust had an additional children’s strategy (2019-2024) which focused on “Putting children and young people at the heart of all we do”. The strategy included workforce and recruitment to deal with capacity issues within the children’s emergency department (CED) which saw an increase of 7.5% in attendances during 2108/19. Staff we spoke with were unaware of any local vision or strategy held by the trust in relation to the emergency department but were aware of the Norfolk and Norwich University Hospitals five-year strategy. This was displayed on posters throughout the hospital informing patients and the public of the trust values and the vision for the future.

Culture Managers across the service did not promote a positive culture that supported and valued staff, or create a sense of common purpose based on shared values. All staff described the hospital as “Their hospital” that they loved and took great pride in. Staff were proud of the emergency department but many staff said they would prefer not to bring a family member to the main ED, especially on busy days. However, despite the heavy demand on the department, staff made the quality of service and patient experience a priority. Staff described a culture of chaos and blame, often referring to being treated badly and bullied by “Them” but we couldn’t fully understand who the term “Them” referred to. There was a cultural divide between nursing and medical staff, staff gave many examples of communication being affected by staff relationships within the department and decisions being routinely overruled and a lack of involvement in decision making. We observed poor interactions between staff, on one occasion a doctor grabbed a set of notes from a student nurse in an abrupt manner, saying “Just give them to me”. We observed on many occasions that staff were often abrupt with each other, and had to seek help from colleagues rather than help being on hand. There was a genuine sense of frustration that staff were not working together well and too many changes were being implemented too quickly. Many of the staff we spoke with described themselves as being tired and hopeless, like nothing was going to change, but when changes did occur they weren’t involved or understood why changes had been made. The culture did not encourage, openness and staff we spoke with said there was a lack of trust when speaking to senior staff and managers. Staff did say this may be because of the new

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 88 changes and staff within the team, however staff routinely told us they felt uncomfortable raising issues regarding the department with the management team. We did see some good cooperative, supportive and appreciative relationships among staff but this was not consistent. For example, working staff with occupational therapists, passing on key details I relation to patient care and coordination with the air ambulance crews.

Governance Governance arrangements are proactively reviewed and reflected best practice. There was an effective governance framework in place. The trust executive board fed into the divisional board, then the sub divisional board and clinical governance committees and then cascaded information to the team meetings. There were monthly emergency department clinical governance meetings. Staff were involved in the trust’s shared governance system. Meetings had an agreed clinical governance agenda and minute action log template for department clinical governance meetings and agreed template reporting from these meetings to divisions. We reviewed board minutes from three governance meetings and observed that the agenda included performance, patient safety, incidents, risk and quality, staffing, health and safety, safety thermometer indicators, infection control and serious incidents. We observed actions identified assigned to individuals with a tracked plan to ensure they were completed. The trust governance structure included the clinical safety and effectiveness committee, none clinical safety committee, the caring and patient experience committee and workforce and education committee.

Management of risk, issues and performance The trust had effective systems for identifying risks, planning to eliminate or reduce them. At the time of our inspection the trust committee structure and content of associated papers were under review by the new chief nurse and medical director to strengthen ward to board oversight of safety and quality. The trust had introduced daily (weekdays) serious incident group meeting chaired by the chief nurse and medical director or agreed deputies held to review all incidents occurring in the previous 24 hours (72 hours post W/E) to identify any immediate safety actions and share learning through discussion. The trust had introduced the chief executive officer assurance panel set up to review Never Events and the most complex serious incidents. All wards had a ward level performance dashboard and monthly performance meetings in place and patient safety and clinical governance were emphasised priorities for divisional reporting at monthly executive performance meetings. Representatives from the emergency department teams (ED) attended mortality and morbidity meetings to look at deaths that occurred in the ED, including any learning or risks identified, which may have contributed to the death. However, nursing staff we spoke with said they did not receive routine feedback from these meetings nor attend them. The trust clinical safety and effectiveness sub-board received reports and information from all four divisions as well as trust-wide governance committees and triangulated messages and themes.

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Clinical safety and effectiveness sub-board reported to management board through the integrated performance report, the safety supplementary reports, slides and the minutes of its meetings. The quality and safety committee (chaired by a non-executive director) received regular reports relating to serious incidents, safety, effectiveness and caring, patient experience and scrutinised and challenged all aspects against a regular schedule of work. Staff we spoke with during our inspection were aware of the risks on the trusts risk register in relation to the emergency department. Staff told us the main risks included ambulance handover delays, lack of qualified children’s nurses within the children’s emergency department and the use of the clinical decisions unit for patients with mental health needs. These risks were on the risk register, and risk rated, with updates on actions taken and who was responsible for oversight of the risks.

Information management The trust collected, analysed, managed and used information to support its activities. Staff we spoke with during our inspection demonstrated to us they had a good understanding of performance across the department and gave examples of how performance was used to try and improve performance across the ED. Staff had access to information they needed to carry out their roles effectively with policies and procedures available on the trust’s intranet, using computer work stations on wheels (COWS). However, the use of both paper and electronic records in the emergency department gave rise to frustration by clinicians on occasions. The emergency department used a small whiteboard to allocate staff to individual bays; this included the name of the medical staff and nursing staff responsible for patients. Staff also used the trusts IT system to identify bed capacity across the hospital. However, staff told us the system was limited and did not always give them a clear picture of capacity to enable them to move patients across the hospital. Throughout our inspection we noted that the IT based patient record and incoming ambulance alert system failed routinely, often whilst staff were involved in handovers with ambulance crews. This led to further delays and huge sense of frustration amongst the staff team, who were unable to rely on the system especially at busy periods. We reviewed the emergency department staff newsletter which had been introduced following our last inspection. The newsletter shared information with staff regarding performance, recruitment activities and audit. Computer screen savers around the department showed information around infection control, safeguarding and other key information for staff.

Engagement The trust did not always engage with its staff team to implement change. The trust had not undertaken any staff surveys within the last 12 months. Staff gave examples of change being implemented without their engagement or consideration being made to their knowledge or expertise. Since our last inspection the trust had implemented the “Greatix” system where staff could message the ED matrons and leave messages regarding any aspects of team work where staff went above and beyond their normal duties, or did something unusual, or just to say thank you for 20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 90 support or kindness. We noted messages from within the team which said, “Thank you for keeping the clinical decisions unit safe during a difficult shift”, another said “Thank you for your awesome work over the weekend”. Patient feedback was by the friends and family test (FFT), through the Patient Advice and Liaison service (PALS) and through “You said we did” comments. The trust had a trauma risk management (TRiM) trained member of staff who is the main contact point for all ED staff. TRiM is the peer-led process that seeks to identify, assist, support and, if necessary, signpost people for further help when they may be at risk of psychological injury after experiencing a traumatic event at work. After traumatic incidents staff names are collected and emailed to the trained staff member who contacts them directly for TRiM session. The trainer has also given a lecture on TRiM at junior doctor teaching sessions. Staff told us they could attend meetings with the chief executive officer, but this depended if their shift hours allowed them to attend. These were often followed up with emails and key information on what was happening at the trust.

Learning, continuous improvement and innovation The trust was committed to improving services by learning from when things go well and when they go wrong. The trust had introduced the UK’s first emergency department that was dedicated to patients over the age of 80, the older person emergency department (OPED). When a patient over 80 years arrived at the ED, staff streamed the patient to the OPED, where there was a multi-disciplinary team consisting of ED consultants, consultant geriatricians, emergency and older people’s medicine nurses waiting to provide care for them. Since our last inspection the trust had increased the size and capacity within its emergency department (ED) based on the needs of the local population. The older peoples’ emergency department (OPED), rapid assessment and treatment (RAT), urgent and emergency care centre (UCC) and children’s emergency department (CED) had significantly increased the size of the environment and responded to the challenges of the increased number of patient attendances.

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Medical care (including older people’s care)

Facts and data about this service The medical care service at Norfolk and Norwich University Hospitals NHS Foundation Trust provides care and treatment for a number of specialities. The trust provides medical care within the following wards. Regional Heart attack centre: • Coronary Care Unit (eight beds) • Kilverstone ward (cardiac ward) • Three cardiac catheter suites • Radial Lounge (six spaces) Older people’s medicine (OPM): • Loddon ward • Kimberley ward • Elsing ward • Brundall ward Respiratory medicine: • Hethel ward • Gunthorpe ward • Respiratory investigation unit The trust provides a neuroscience service which includes a Hyper-Acute Stroke Unit (HASU) located on Heydon ward. Further treatment and rehabilitation is provided on the Acute Stroke Unit (ASU) on Dunston Ward. Cardiology at the trust consists of eight coronary care beds, 37 beds on Kilverstone ward, a cardio elective bay facility comprising eight radial chairs and a bedded area and access to Aylsham Day Unit for day case non-procedure patients such as those receiving intravenous antibiotics. Gastroenterology at the trust consists of Guist Ward and a day-case facility, which provides diagnostic and therapeutic endoscopy, colonoscopy and flexible sigmoidoscopy located in the Quadram Institute. The Quadram Institute is a multi-million-pound state-of-the-art food and health research and endoscopy centre opened in autumn 2018. The Quadram hosts the Norfolk and Norwich University Hospitals’ regional gastrointestinal endoscopy facility which will be the largest Endoscopy Unit in Europe. The Quadram is also home to the East of England Bowel Cancer Screening Programme. Inpatient elective and non-elective endoscopy are delivered in the gastroenterology unit in the Norfolk and Norwich Hospital. An Acute Renal Unit is located on Langley Ward. The Jack Pryor Haemodialysis Unit (JPU) provides a full dialysis service at NNUH. The trust also has a satellite dialysis service, which is located at Cromer Hospital. The Rheumatology Regional Centre of Excellence includes a day unit (RDU) with eight chairs for treatment of rheumatic diseases.

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Inpatient oncology and haematology services are provided on Mattishall ward and Aylsham discharge suite. Day-case chemotherapy is provided by the Weybourne day unit (WDU). Endocrinology consists of Earsham ward and a clinical investigation unit with two spaces. (Source: Routine Provider Information Request AC1 - Acute context)

The trust had 97,273 medical admissions from August 2017 to July 2018. Emergency admissions accounted for 29,066 (29.9%), 2,385 (2.5%) were elective, and the remaining 65,822 (67.7%) were day case. Admissions for the top three medical specialties were: • Gastroenterology: 26,168 admissions • Clinical oncology: 21,299 admissions • General medicine: 16,303 admissions (Source: Hospital Episode Statistics) During the inspection we visited ten wards including Elsing, Mulbarton, Dunston, Kimberley, Langley, Earsham, Heydon, Guist, Gunthorpe and Mattishall. We visited the Quadram Institute, the acute medical unit (AMU) and the Jack Pryor unit. We carried out an unannounced part of the inspection on 6 February 2019. We spoke with 52 staff including the chief of division, director of division, the division nurse director, 29 registered nurses (RNs), three health care assistants (HCAs), 12 doctors, two consultants, one physiotherapist, one pharmacist and one tissue viability nurse (TVN). We spoke with eight patients and four relatives or carers. We reviewed nine sets of patient medical notes and eight patient nursing notes.

Is the service safe? By safe, we mean people are protected from abuse* and avoidable harm. *Abuse can be physical, sexual, mental or psychological, financial, neglect, institutional or discriminatory abuse. Mandatory training The service provided mandatory training in key skills to all staff. The trust provided mandatory training in a variety of topics. Some topics were delivered by face to face training and others were by e-Learning. The trust set a target of 90% for completion of mandatory training. A breakdown of compliance for mandatory training courses at September 2018 at trust level for qualified nursing staff in medicine is shown below:

Number Number of of staff eligible trained staff Completion Trust Met Name of course (YTD) (YTD) rate Target (Yes/No) Infection Prevention (Level 1) 1 1 100% 90% Yes

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Health and Safety (Slips, Trips and Falls) 661 709 93% 90% Yes Fire Safety 621 709 88% 90% No Medicine management training 577 686 84% 90% No Information Governance 563 709 79% 90% No Manual Handling - Object 11 14 79% 90% No Venous Thromboembolism 528 674 78% 90% No Infection Prevention (Level 2) 549 703 78% 90% No Blood Transfusion 409 530 77% 90% No Equality and Diversity 547 709 77% 90% No Adult Basic Life Support 542 703 77% 90% No Manual Handling - People 527 691 76% 90% No Clinical Record Keeping 521 699 75% 90% No Prevention & Management of Aggression 106 197 54% 90% No

In medicine the 90% target was met for two of the 14 mandatory training modules for which qualified nursing staff were eligible. Mandatory training compliance across all the wards we visited was inconsistent, some wards reached or exceeded the trust target for some topics. At the time of inspection mandatory training compliance overall was still below the trust target of 90% at 79%. We had raised this as a concern at our previous inspection. Some wards reached or exceeded the trust target for basic life support and other wards, for example Mulbarton, Langley and Mattishall were significantly below it at 52%, 69% and 61% respectively. Ward managers and matrons reviewed the ward dashboard, including mandatory training compliance, as part of monthly meetings and ward managers displayed mandatory training compliance figures at the entrance to each ward. Some ward managers had introduced local incentives for mandatory training completion, for example, Mulbarton ward displayed a mandatory training leader board and Earsham provided afternoon tea vouchers for those staff who were 100% compliant. All the staff we spoke with could describe the trust procedures they would follow in the event of a patient developing sepsis. Sepsis training was part of basic life support training. Posters displayed in all wards we visited provided staff with information on detecting and managing sepsis. Nursing care records had an aide memoire as part of the early warning scores. A breakdown of compliance for mandatory training courses from at September 2018 at trust level for medical staff in medicine is shown below:

Number Number of of staff eligible trained staff Completion Trust Met Name of course (YTD) (YTD) rate Target (Yes/No) Infection Prevention (Level 2) 1 1 100% 90% Yes Resuscitation 17 19 89% 90% No Health and Safety (Slips, Trips and Falls) 255 285 89% 90% No Blood Transfusion 212 251 84% 90% No Medicine management training 227 269 84% 90% No Clinical Record Keeping 211 276 76% 90% No 20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 94

Infection Prevention (Level 3) 207 275 75% 90% No Adult Basic Life Support 197 270 73% 90% No Fire Safety 206 285 72% 90% No Venous Thromboembolism 186 276 67% 90% No Manual Handling - Object 169 278 61% 90% No Equality and Diversity 161 285 56% 90% No Information Governance 147 285 52% 90% No

In medicine the 90% target was met for one of the 13 mandatory training modules for which medical staff were eligible. (Source: Routine Provider Information Request (RPIR) – Training tab)

Safeguarding Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it. The trust had clear policies and processes in place around safeguarding. All the staff we spoke with could describe how they would identify and raise a safeguarding concern. Posters displayed in the ward areas we visited provided staff with additional guidance. A breakdown of compliance for safeguarding training courses at September 2018 at trust level for qualified nursing staff in medicine is shown below:

Number of Number of eligible staff trained staff Completion Trust Met Name of course (YTD) (YTD) rate Target (Yes/No) Safeguarding Adults (Level 2) 656 704 93% 90% Yes Safeguarding Children (Level 2) 632 680 93% 90% Yes Safeguarding Children (Level 3) 22 25 88% 90% No PREVENT - Level 3 547 669 82% 90% No

In medicine the 90% target was met for two of the four safeguarding training modules for which qualified nursing staff were eligible. At the time of inspection nursing safeguarding training compliance for safeguarding adults level 2 was met or exceeded for all the wards we visited. This was an improvement on our previous inspection where nurse safeguarding adults level 2 training compliance was 89%. A breakdown of compliance for safeguarding training courses at September 2018 at trust level for medical staff in medicine is shown below:

Number of Number of eligible staff trained staff Completion Trust Met Name of course (YTD) (YTD) rate Target (Yes/No) Safeguarding Adults (Level 2) 176 278 63% 90% No Safeguarding Children (Level 2) 149 250 60% 90% No 20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 95

Safeguarding Children (Level 3) 16 27 59% 90% No PREVENT - Level 3 147 257 57% 90% No Safeguarding Children (Level 1) 0 1 0% 90% No

In medicine the 90% target was met for none of the five safeguarding training modules for which medical staff were eligible. Compliance was low across all five modules with the safeguarding adults (level 2) course having the highest completion rate (63%). (Source: Routine Provider Information Request (RPIR) – Training tab)

Cleanliness, infection control and hygiene The service controlled infection risk well. Staff kept equipment and the premises clean. They used control measures to prevent the spread of infection. Nursing staff completed mandatory infection prevention and control level 2 training. The trust set a target of 90% compliance. At the time of our inspection, training compliance was 80% except for Kimberley, Heydon and Mattishall wards that all met the trust target. Staff wore personal protective equipment (PPE) such as disposable gloves and aprons when providing patient care. Nursing staff had bare arms below the elbow in line with infection prevention and control guidelines and adhered to the trust wide uniform policy. Staff washed and sanitised their hands between episodes of patient care and wiped over equipment between patient contacts. Posters displayed at ward entrances and beside sinks encouraged staff and visitors to adhere to “5 moments of hand hygiene”. Ward staff carried out hand hygiene audits monthly. Ward managers and matrons discussed hand hygiene compliance as part of ward dashboard meetings. Ward managers displayed audit results on a white board at the entrance to the ward. Data supplied by the trust showed hand hygiene compliance on all the wards we visited was over 98% for the period, September 2018 to January 2019. This met the trust target. Staff completed monthly ward cleaning audits. The trust wide target for compliance was 95%. All the wards we visited consistently achieved or exceeded trust target for the period December 2017 to December 2018. Staff explained the protocol for patients with possible infectious disease and demonstrated they had good understanding of infection, prevention, promotion, and control in their day-to-day activities with patients. On Kimberley ward and Langley ward, nursing staff had identified patients who had been risk assessed as requiring nursing in isolation as part of infection prevention and control measures. All side room doors were closed in line with the risk assessment. This was an improvement since our last inspection where staff did not consistently close doors where required. We were unable to access Kilverstone ward during our initial inspection due to the ward being closed due to Norovirus. The ward doors displayed clear signage advising the ward was closed and advising staff and visitors what precautions to take regarding hand hygiene and infection control if they entered the ward.

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We were unable to enter one bay in AMU (H) ward due to flu. Nursing staff kept bay doors closed and used appropriate personal protective equipment (PPE), including face masks, when entering the area. In the endoscopy unit we observed suitable processes for the handling and decontamination of contaminated endoscopes. The service had a clear decontamination route for infection control purposes which meant clean and used (contaminated endoscopes) were kept separate, with full tracking and traceability systems in place. This was in line with national guidance.

Environment and equipment The service had suitable premises and equipment and looked after them well. All wards we visited had controlled access in place, to restrict unauthorised access into the ward areas. Wards were laid out in a circle, with bays off a central hub area which had the nurse's station, toilets, kitchenette and clean and dirty utility areas. We reviewed 14 pieces of equipment across the wards we visited including commodes, hoists and blood pressure monitors. Staff had cleaned and labelled equipment appropriately. All the equipment had been serviced and electrical tested as required. Staff consistently completed daily and weekly resuscitation equipment checks across all the wards we visited. This was an improvement on our last inspection where staff did not complete checks consistently. Patient cupboards, equipment, and curtains around bed spaces appeared visibly clean throughout the wards we visited. Disposable curtains displayed an expiry check date and we found all curtains to be within the expiry date and in good condition. Cleaning staff replaced fabric curtains on a three-monthly basis or sooner if they became soiled. Curtain change records evidenced cleaning staff had changed fabric curtains in December 2018. Patient bays and side rooms had clear signage to inform staff on entry if there were any specific issues, for example, if the patient was living with dementia, had a pressure area, or required hearing support. This enabled staff to identify any specific patient needs prior to approaching the patient. On Elsing ward we were concerned the ward appeared cluttered. Staff left trailing cables from equipment being charged, cleaning staff had left “wet floor” warning signs in place throughout the ward despite the floor being dry. We raised this with ward staff at the time and our concerns were immediately addressed. On Elsing ward, the day room was being used for family and doctor discussions and we observed a consultant discussing ceilings of care with a relative in the busy central hub area of the ward. We challenged the consultant on the appropriateness of this location for such a discussion and they explained there was no alternative space available. The Quadram building contained a brand new, purpose built endoscopy unit. The design was open and spacious with a one-way system for patients, pre and post procedure, kept separate for infection prevention and control. There were separate male and female waiting rooms, consulting rooms, rooms for bowel preparation with ensuite toilet facilities, 10 endoscopy rooms, of which eight were in use at the time of inspection and a spacious recovery area. The unit also had its own cleaning and sterilising department.

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The senior executive team were aware that equipment which was bought new at the time of opening the hospital was now aging. The medical leads described a plan for the replacement of dialysis equipment.

Assessing and responding to patient risk Staff completed and updated risk assessments for each patient. They kept clear records and asked for support when necessary. Nursing staff had completed required risk assessments in all the eight nursing records we reviewed. Nursing staff signed and dated them and acted on the outcome. For example, using pressure relieving equipment where Waterlow scores identified a patient at risk of pressure sores. On Earsham ward, nursing staff displayed clocks above the beds of patients who were at risk of pressure sores. Nursing staff told us the clocks were an added prompt to pay extra attention to pressure areas and timely patient repositioning. On Kimberley ward, nursing staff displayed pictures of pressure relieving booties on the doors and bedsides of those patients who were at risk of pressure sores on the feet. These acted as an aide memoir for nursing staff. Ward managers had displayed the sepsis toolkit and escalation bundle in easily accessible places on all the wards we visited. Nursing staff completed patient observations using early warning scores (EWS). In the eight nursing records we reviewed, nursing staff had completed EWS correctly and escalated appropriately when required. Nursing staff on Earsham ward were piloting national early warning scores (NEWS) 2 and the trust planned to roll this out in March 2019. All ward staff attended a safety huddle at each shift handover. This ensured all staff were aware of any patients who required one to one nursing or were acutely unwell. Nursing staff told us, even though there were shortages of middle grade doctors, they could always access medical input from a doctor in a timely way. Doctors told us they could always access advice and support from consultants. Nursing staff told us they could contact the critical care outreach team between 8am and 8.30pm seven days per week if they felt a patient had deteriorated rapidly. The trust used a hospital at night team coordinated by the site team overnight. Medical staff had reviewed patients in a timely way in all the nine medical records we reviewed. This was in line with the London Quality Standards (February 2013). Nursing staff in the endoscopy unit completed the world health organisation (WHO) and five steps to safer surgery checklist prior to, during and post endoscopy procedures.

Nurse staffing The service did not have enough nursing staff with the right qualifications, skills, training and experience. The service was actively recruiting nursing staff of all grades and used bank and agency staff to keep people safe from avoidable harm and to provide the right care and treatment.

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Ward managers used a safer staffing tool and considered patient acuity when determining ward staffing levels. Nurses and health care assistants (HCAs) discussed staffing levels as part of the safety huddle at each shift handover. This meant ward managers were aware at the earliest opportunity of any staffing issues for the shift and could escalate any staffing concerns. The trust has reported their staffing numbers at March 2018 and at September 2018 for qualified nursing staff in medicine. The number of actual staff (WTE) has remained stable between the two points in time, although the trust has increased their planned establishment for nursing staff in medicine. For this reason, the fill rate has decreased from 84.2% in March 2018 to 75.3% in September 2018. As at March 2018 As at September 2018 Actual Planned Actual staff – staff – staff – Planned Site WTE WTE Fill rate WTE staff – WTE Fill rate Trust wide 611.2 726.2 84.2% 606.3 805.0 75.3% (Source: Routine Provider Information Request (RPIR) –Total staffing tab) From September 2017 to August 2018, the trust reported a vacancy rate of 18.5% for qualified nursing staff in medicine. The trust does not have a target for vacancy rate. (Source: Routine Provider Information Request (RPIR) – Vacancy tab) Most of the wards we visited had vacancies for either registered nurses (RN) or HCAs. The trust told us “Following discussion with the clinical teams, the division has increased its nursing establishment and is actively recruiting using multiple new platforms”. The medical triumvirate described a ward specific targeted recruitment drive both locally, nationally and internationally and how, using this approach, they had been able to recruit endoscopy nurses to establishment. The trust had recently held an open night for recruitment of HCAs. Each ward showcased their ward speciality and the medicine division had recruited more than 100 HCAs. The medicine division has a dedicated human resources person to specifically address recruitment issues on medical wards. From October 2017 to September 2018, the trust reported a turnover rate of 7.7% for qualified nursing staff in medicine. This was lower than the trust target of 10.0%. (Source: Routine Provider Information Request (RPIR) – Turnover tab) From September 2017 to August 2018, the trust reported a sickness rate of 4.0% for qualified nursing staff in medicine. This was higher than the trust target of 3.5%. (Source: Routine Provider Information Request (RPIR) – Sickness tab) From September 2017 to August 2018, the trust reported that 336,942 of the 2,247,062 establishment hours were filled by bank staff (15.0%) and 132,221 hours were filled by agency staff (5.9%). There were 254,755 hours (11.3%) that needed to be covered by bank or agency staff but were unfilled. A breakdown of bank and agency usage by staff type is shown below: Total establishment Staff type Bank hours Agency hours Unfilled hours hours Qualified 32,866 (2.2%) 54,489 (3.7%) 199,452 (13.6%) 1,467,464

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Non-qualified 304,077 (39.0%) 77,732 (10.0%) 55,303 (7.1%) 779,598 Total 336,942 (15.0%) 132,221 (5.9%) 254,755 (11.3%) 2,247,062 (Source: Routine Provider Information Request (RPIR) - Nursing bank agency tab) The wards used agency or bank staff on a daily basis usually between 12 mid-day and 12pm to mitigate the vacancy numbers and reduce risk to patient safety. Supernumerary trainee nurses were often used to provide one to one “specialling” care to patients who required it. Staff displayed the number of staff on duty both planned and actual at the entry to wards to enable staff, patients, and family members to see staffing levels on the ward. At the time of inspection all the wards we visited, except Elsing, reported nurse staffing to be “as planned”. Elsing ward was one RN below planned but six HCA above planned to mitigate risks to patient care.

Medical staffing The service did not have enough medical staff with the right qualifications, skills, training and experience. The service was actively recruiting medical staff of all grades and used locum staff to keep people safe from avoidable harm and to provide the right care and treatment. The trust reported their staffing numbers at March 2018 and at September 2018 for medical and dental staff in medicine. The number of actual staff (WTE) has increased over time, although the trust has increased their planned establishment for medical and dental staff in medicine. For this reason, the fill rate has decreased from 93.8% in March 2018 to 87.2% in September 2018. As at March 2018 As at September 2018 Actual Planned Actual staff – staff – staff – Planned Site WTE WTE Fill rate WTE staff – WTE Fill rate Trust wide 281.0 299.7 93.8% 289.0 331.5 87.2%

(Source: Routine Provider Information Request (RPIR) –Total staffing tab) From September 2017 to August 2018, Norfolk and Norwich University Hospital reported a vacancy rate of 10.0% for medical and dental staff in medicine. The trust does not have a target for vacancy rate. (Source: Routine Provider Information Request (RPIR) – Vacancy tab) The medical triumvirate described a ward specific targeted recruitment drive both locally, nationally and internationally and how, using this approach, they had been able to recruit an additional eight middle grade doctors from India. Medical staffing service wide was, on the whole, five junior doctors from 8am until 4pm supported by registrars and consultants. One junior doctor per speciality worked a long day, until 9pm, when the hospital at night (HaN) team took over. This out of hours team was three registrars and five junior doctors. This was an improvement from our previous inspection where there had been only one registrar. On the neurology ward (Heydon) medical cover was one registrar, two junior doctors and one consultant during the weekday 8.30am until 5.30pm. At least one junior doctor was responsible for their medical specialty during the hours of 5.30pm until 9pm. In the speciality of neurosciences this

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 100 was one newly qualified (August 2018) FY1 (foundation year). The FY1 was able to obtain support from another, more experienced, medical colleague in the hospital if required. In cardiology a cardiology registrar provided on call out of hours cover to ensure specialist cardiac care was available for cardiology patients. Weekend day medical cover was generally one junior doctor, one registrar and one consultant per specialty except for cardiology where an additional junior doctor was available on Saturday mornings to process patient discharges. All the medical staff we spoke with told us they felt medical staffing was safe despite a shortage of junior grade doctors. Junior doctors told us they felt supported by more senior colleagues and consultants. From October 2017 to September 2018, the trust reported a turnover rate of 3.8% for medical and dental staff in medicine. This was lower than the trust target of 10.0%. (Source: Routine Provider Information Request (RPIR) – Turnover tab) From September 2017 to August 2018, the trust reported a sickness rate of 1.0% for medical and dental staff in medicine. This was lower than the trust target of 3.5%. (Source: Routine Provider Information Request (RPIR) – Sickness tab) From September 2017 to August 2018, the trust reported that 13,687 of the 622,045 establishment hours were filled by bank staff (2.2%) and 345 hours were filled by medical locum staff (5.9%). There were 75,226 hours (12.1%) that needed to be covered by bank or medical locum staff but were unfilled. A breakdown of bank and medical locum usage by unit/ward is shown below: Total establishment Unit/ward Bank hours Locum hours Unfilled hours hours Cardiology 959 (1.3%) 161 (0.2%) 9,031 (12.1%) 74,418 Dermatology 327 (0.7%) 0 0 49,578 Endocrinology 436 (0.9%) 24 (<0.1%) 5,625 (11.2%) 50,287 Gastroenterology 1,165 (1.4%) 0 10,324 (12.3%) 83,742 Nephrology 423 (1.0%) 0 3,233 (7.8%) 41,714 Neurology 739 (1.9%) 0 10,032 (25.3%) 39,691 Older peoples medicine 6,337 (4.8%) 160 (0.1%) 17,937 (13.7%) 131,400 Oncology 484 (0.8%) 0 8,239 (13.6%) 60,590 Respiratory 2,415 (4.0%) 0 6,779 (11.2%) 60,486 Rheumatology 404 (1.3%) 0 4,025 (13.4%) 30,139 Total 13,687 (2.2%) 345 (0.1%) 75,226 (12.1%) 622,045 (Source: Routine Provider Information Request (RPIR) - Medical agency locum tab) As at July 2018, the proportion of consultant staff reported to be working at the trust was higher than the England average and the proportion of junior (foundation year 1-2) staff was lower.

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Staffing skill mix for the 246-whole time equivalent staff working in medicine at Norfolk and Norwich University Hospitals NHS Foundation Trust This England Trust average Consultant 50% 42% Middle career^ 9% 6% Registrar group~ 24% 27% Junior* 16% 25%

^ Middle Career = At least 3 years at SHO or a higher grade within their chosen specialty ~ Registrar Group = Specialist Registrar (StR) 1-6 * Junior = Foundation Year 1-2 Source: NHS Digital - Workforce Statistics - Medical (01/07/2018 - 31/07/2018) In the majority of wards we visited, consultant medical staff reviewed patients twice weekly, with registrars reviewing patients on a daily basis. This was evidenced in the nine sets of medical notes we reviewed. On AMU, consultants carried out twice daily ward rounds. Each consultant had clinical responsibility for inpatients who were not accommodated in their base ward but were located elsewhere. Such patients are termed ‘outliers’. We reviewed the medical records of three outlier patients and timely medical review was evidenced in all of the medical records. The trust was upskilling nursing staff, for example clinical nurse specialists, to mitigate risks associated with junior grade doctor vacancies.

Records Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date and easily available to all staff providing care. We reviewed eight patient nursing records and nine medical records as part of this inspection. Staff kept patient nursing records either outside the patient’s room or at the end of the patient’s bed in closed folders. Staff kept medical records in record trolleys beside nurse stations. The trust used a combination of paper and electronic patient records. Notes were accessible to all staff. In all the wards we visited staff had closed the lids on the record trolleys to protect patient confidentiality. Staff did not leave patient records open, on workstations on wheels or counters when unattended. Staff logged out of workstations on wheels so that patient’s details were not visible on the computer screen, without staff in attendance. This was an improvement on our last inspection. Nursing staff completed nursing records to a good standard, and completed risk assessments and reviews frequently during the patient’s admission. Risk assessments included Early Warning

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Scores (EWS), malnutrition universal screening tool (MUST), Waterlow pressure scores, and falls risk assessments amongst others. Three of the nine records we reviewed contained do not attempt cardiopulmonary resuscitation (DNACPR) orders. Staff had completed these appropriately with clear evidence of involvement of patients and the families. We found good evidence of multidisciplinary team recording in patient records. Different staff groups used a specifically coloured sticker to identify any entries made in the patient’s medical notes. For example, physiotherapists used a blue sticker.

Medicines The service followed best practice when prescribing, giving, recording and storing medicines. Patients received the right medication at the right dose at the right time. Staff stored medicines safely in line with trust policy in all the wards we visited. Staff locked and secured drug trolleys. This was an improvement on our last inspection where medicines were not always stored securely. Staff stored controlled drugs (CDs) appropriately in all wards we visited. CD records we checked confirmed staff reconciled CDs in line with trust policy and without omissions. We spoke with a pharmacist who demonstrated the trusts electronic medication system. They explained that the system limited errors and identified changes in patient medication, making it simpler for staff to record and identify patients who may be at risk from changes in medication or any omissions. Staff used workstations on wheels to administer medication rounds and utilise the electronic medications system. We observed a medication round, it was well managed, calm and staff carried out appropriate patient checks before dispensing or administering medication. Recording and monitoring of medicine fridge temperatures across the wards we visited was not consistent. On Langley ward and Elsing ward nursing staff recorded fridge temperatures with no omissions (December 2018 to January 2019). On Dunston ward, staff had not checked fridge temperatures on eight days between December 2018 and January, on Kimberley ward fridge temperatures had not been checked on three days in November 2018 and three days in December 2018, on Mulbarton ward temperatures had not been checked on eight days in January, on AMU (H) staff had not recorded temperatures on six days in December 2018 and four days in January 2019. On Guist ward staff did not record medicine fridge temperatures at weekends. We were not assured that medications were stored at the correct temperature to ensure efficacy. We highlighted this as a concern at our previous inspection.

Incidents The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support. Never events are serious incidents that are entirely preventable as guidance, or safety recommendations providing strong systemic protective barriers, are available at a national level, and should have been implemented by all healthcare providers.

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From November 2017 to October 2018, the trust reported no incidents classified as never events for medicine. (Source: Strategic Executive Information System (STEIS)) In accordance with the Serious Incident Framework 2015, the trust reported 68 serious incidents (SIs) in medicine which met the reporting criteria set by NHS England from November 2017 to October 2018. The breakdown by incident type was as follows: • Pressure ulcer meeting SI criteria with 32 (47% of total incidents). • Slips/trips/falls meeting SI criteria with 20 (29% of total incidents). • HCAI/Infection control incident meeting SI criteria with five (7% of total incidents). • Treatment delay meeting SI criteria with three (4% of total incidents). • Confidential information leak/information governance breach meeting SI criteria with two (3% of total incidents). • Sub-optimal care of the deteriorating patient meeting SI criteria with one (1% of total incidents). • Commissioning incident meeting SI criteria with one (1% of total incidents). • Abuse/alleged abuse of adult patient by staff with one (1% of total incidents). • Pending review (a category must be selected before incident is closed) with one (1% of total incidents). • Medical equipment/ devices/disposables incident meeting SI criteria with one (1% of total incidents). • Medication incident meeting SI criteria with one (1% of total incidents). (Source: Strategic Executive Information System (STEIS)) Staff could describe the electronic incident reporting system and knew what would be classed as an incident. Ward managers displayed the number of incidents which had occurred on the ward the previous month on a white board at the ward entrance. Staff could describe what the incidents had been and what had happened because of them. A nurse on Kimberley ward described an incident where a patient who had meant to be receiving one to one nursing care fell. As a result of the investigation the ward introduced a “buddy system” so that should the nurse or HCA providing one to one care needed to leave the patient they had a named person to hand care over to. The trust held a weekly safety improvement group (SIG) meeting which all staff were invited to attend. One ward manager described how they had attended a meeting and taken two health care assistants (HCA) with them to ensure shared learning from incidents. In some of the wards we visited ward managers displayed route cause analysis (RCAs) from previous incidents in staff areas. This ensured learning from incidents was shared. All the staff we spoke with about the Duty of Candour were aware of the regulation and had a good understanding of when it would be triggered. The Duty of Candour is a regulatory duty that relates to openness and transparency and requires providers of health and social care services to

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 104 notify patients (or other relevant persons) of certain notifiable safety incidents and provide reasonable support to that person. The medical division reviewed morbidity and mortality (M&M) as part of the monthly governance meeting. Meetings were multidisciplinary and included the speciality governance lead, the chief of service, the senior operations manager and the matron for each service plus the medical director. A senior leader explained the M&M meeting format was work in progress and needed further embedding. The trust wide mortality surveillance group considered aspects of mortality and contributing factors across the divisions.

Safety thermometer The Safety Thermometer is used to record the prevalence of patient harms and to provide immediate information and analysis for frontline teams to monitor their performance in delivering harm free care. Measurement at the frontline is intended to focus attention on patient harms and their elimination. Data collection takes place one day each month – a suggested date for data collection is given but wards can change this. Data must be submitted within 10 days of suggested data collection date. Data from the Patient Safety Thermometer showed that the trust reported 61 new pressure ulcers, 29 falls with harm and 21 new urinary tract infections in patients with a catheter from October 2017 to October 2018 for medical services.

Prevalence rate (number of patients per 100 surveyed) of pressure ulcers at Norfolk and Norwich University Hospitals NHS Foundation Trust

1 Total Pressure ulcers (61)

2 Total Falls (29)

3 Total CUTIs (21)

1 Pressure ulcers levels 2, 3 and 4 2 Falls with harm levels 3 to 6

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3 Catheter acquired urinary tract infection level 3 only Source: NHS Digital - Safety Thermometer Some wards displayed the safety thermometer in staff areas. Staff discussed findings from the safety thermometer at their team meetings and stored meeting minutes in the ward “Green folder”. We reviewed meeting minutes on Kilverstone ward dated November 2018. Earsham ward described how they had recently (May 2018) taken part in the pressure ulcer (PU) collaborative. This had led to a 60% decrease in unavoidable PUs and the ward was 91 days pressure ulcer free as a result of the learning. The trust told us they were introducing an internal Essential Care Scrutiny Panel to review all Pressure ulcers and falls among other issues.

Is the service effective? Evidence-based care and treatment The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance. The trust told us they had a Trust policy for the implementation of National Institute for Health and Care Excellence (NICE) guidance to ensure that the trust has a clear process to respond effectively to NICE guidance updates. These updates bring benefits to patients, ensuring that care provided is the most clinically and financially effective. The relevant divisional board was responsible for confirming compliance status. Staff accessed trust policies and procedures on the intranet. Nursing staff demonstrated how to do this. Patient care pathways followed National institute for health and care excellence (NICE) guidance. The stroke pathway and treatment plan through the hyper acute stroke unit (HASU) into the acute stroke unit followed CG68; Stroke and transient ischaemic attack in over 16s: diagnosis and initial management (2008) with good performance for time to diagnosis and treatment as demonstrated by audit. Pathways for patients having a heart attack were in line with NICE guidance CG167; Myocardial infarction with ST-segment elevation: acute management and rehabilitation and CG172; Myocardial infarction: cardiac rehabilitation and prevention of further cardiovascular disease. Consultants reviewed patients on the acute medical unit (AMU) twice daily, at 8am and 5pm seven days a week. Registrars reviewed ward based patients during a daily ward round and consultants reviewed patients at least twice per week. Medical staff carried out endoscopic procedures in line with professional guidance. World health organisation (WHO) and five steps to safer surgery checklist audits completed monthly demonstrated 100% compliance in December 2018 and January 2019.

Nutrition and hydration Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary. The service made dietary adjustments for patients’ religious, cultural and other preferences.

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Nursing staff assessed patients’ nutritional status and referred them to a dietician where necessary. Nursing staff completed malnutrition universal screening tools (MUST) accurately and updated them to reflect patients changing needs. Patients were prescribed nutritional supplements to enhance their wellbeing where required. Patients who were unable to take nutrition and hydration orally were supported with intravenous fluids and other forms of delivering nutrition, for example through nasogastric (NG) tubes or percutaneous endoscopic gastrostomy (PEG). Nursing staff placed dated stickers into patient medical notes to identify the enteral feed for traceability. Nursing staff completed food and fluid charts accurately in all the nursing notes we reviewed. One HCA described how they supported patients to choose from the menu each day and told us that they involve family members to help identify foods the patient likes to eat if the patient is unable to do this for themselves. We reviewed the menu offered to patients and saw it catered for people of different faiths and cultures as well as those patients who needed a soft diet or were vegetarian. Those patients who required assistance during meal times were identified with a symbol of a red tray beside the bed.

Pain relief Staff assessed and monitored patients regularly to see if they were in pain. They supported those unable to communicate using suitable assessment tools and gave additional pain relief to ease pain. The service had implemented the Faculty of Pain Medicine’s Core Standards for Pain Management (2015). Nursing staff completed and recorded intentional rounding checks every two hours in all the nursing records we checked. Nursing staff checked patients were comfortable and had appropriate levels of pain relief. Nursing staff used a recognised pain scoring tool to monitor pain in patients who were not able to communicate verbally. An acute pain team was available during working hours to review patients requiring analgesia. Out of hours this was the responsibility of the on-call anaesthetist. All the patients we spoke with told us their pain was managed appropriately. Pain relief was available in a number of ways including orally, by injection and, for some patients who could not tolerate oral medicines, by syringe driver.

Patient outcomes Managers monitored the effectiveness of care and treatment compared with other local and national providers but did not consistently use the findings to improve them. The service took part in national audits but did not consistently develop robust action plans to improve quality based on audit findings. The trust wide audit team shared national audit compliance reports at divisional governance meetings.

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Trust level From July 2017 to June 2018, patients at the trust had a lower than expected risk of readmission for elective admissions and a lower than expected risk of readmission for non-elective admissions when compared to the England average. • Patients in clinical oncology had a lower than expected risk of readmission for elective admissions • Patients in gastroenterology had a lower than expected risk of readmission for elective admissions • Patients in clinical haematology had a lower than expected risk of readmission for elective admissions

Elective Admissions – Trust Level

Note: Ratio of observed to expected emergency readmissions multiplied by 100. A value below 100 is interpreted as a positive finding, as this means there were fewer observed readmissions than expected. A value above 100 represents the opposite. Top three specialties for specific trust based on count of activity.

• Patients in general medicine had a lower than expected risk of readmission for non-elective admissions • Patients in geriatric medicine had a lower than expected risk of readmission for non-elective admissions • Patients in cardiology had a lower than expected risk of readmission for non-elective admissions

Non-Elective Admissions – Trust Level

Note: Ratio of observed to expected emergency readmissions multiplied by 100. A value below 100 is interpreted as a positive finding, as this means there were fewer observed readmissions than expected. A value above 100 represents the opposite. Top three specialties for specific trust based on count of activity. (Source: Hospital Episode Statistics - HES - Readmissions (01/07/2017 - 30/06/2018))

Norfolk and Norwich University Hospital

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From July 2017 to June 2018, patients at Norfolk and Norwich University Hospital had a lower than expected risk of readmission for elective admissions and a lower than expected risk of readmission for non-elective admissions when compared to the England average. • Patients in clinical oncology had a lower than expected risk of readmission for elective admissions • Patients in gastroenterology had a lower than expected risk of readmission for elective admissions • Patients in clinical haematology had a lower than expected risk of readmission for elective admissions

Elective Admissions - Norfolk and Norwich University Hospital

Note: Ratio of observed to expected emergency readmissions multiplied by 100. A value below 100 is interpreted as a positive finding, as this means there were fewer observed readmissions than expected. A value above 100 represents the opposite. Top three specialties for specific site based on count of activity.

• Patients in general medicine had a lower than expected risk of readmission for non-elective admissions • Patients in geriatric medicine had a lower than expected risk of readmission for non-elective admissions • Patients in respiratory medicine had a higher than expected risk of readmission for non- elective admissions

Non-Elective Admissions - Norfolk and Norwich University Hospital

Note: Ratio of observed to expected emergency readmissions multiplied by 100. A value below 100 is interpreted as a positive finding, as this means there were fewer observed readmissions than expected. A value above 100 represents the opposite. Top three specialties for specific site based on count of activity.

Cromer Hospital From July 2017 to June 2018, patients at Cromer Hospital had a lower than expected risk of readmission for elective admissions when compared to the England average.

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• Patients in clinical haematology had a lower than expected risk of readmission for elective admissions • Patients in clinical oncology had a lower than expected risk of readmission for elective admissions • Patients in dermatology had a higher than expected risk of readmission for elective admissions

Elective Admissions - Cromer Hospital

Note: Ratio of observed to expected emergency readmissions multiplied by 100. A value below 100 is interpreted as a positive finding, as this means there were fewer observed readmissions than expected. A value above 100 represents the opposite. Top three specialties for specific site based on count of activity.

Non-Elective Admissions - Cromer Hospital Cromer hospital only has elective medical activity so there are no non-elective admissions. (Source: Hospital Episode Statistics)

Sentinel Stroke National Audit Programme (SSNAP) Norfolk and Norwich University Hospital Norfolk and Norwich University Hospital takes part in the quarterly Sentinel Stroke National Audit programme. On a scale of A-E, where A is best, the trust achieved grade B in latest audit, December 2017 to March 2018. Performance was worst for the domain relating to the hospital’s stroke unit where a grade E was awarded. In the most recent audit, the trust achieved a grade A for standards by discharge, discharge processes and occupational therapy (team centred performance).

Dec 16 Apr 17 Aug 17 - Dec 17 - Patient centred performance -Mar 17 -Jul 17 Nov 17 Mar 18 Domain 1: Scanning B C↓ B↑ C↓ Domain 2: Stroke unit D↓ D D E↓ Domain 3: Thrombolysis C↓ C B↑ C↓ Domain 4: Specialist assessments B↓ B A↑ B↓ Domain 5: Occupational therapy C↓ C C B↑ Domain 6: Physiotherapy B B B B Domain 7: Speech and language C D↓ C↑ C therapy Domain 8: Multi-disciplinary team C↓ C B↑ C↓ working Domain 9: Standards by discharge B A↑ B↓ A↑

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Domain 10: Discharge processes A A A A Patient-centred total key indicator B C↓ B↑ B level

Dec 16 Aug 17 Dec 17 - Mar Apr 17 - Nov - Mar Team centred performance 17 -Jul 17 17 18 Domain 1: Scanning B C↓ B↑ C↓ Domain 2: Stroke unit D↓ D D E↓ Domain 3: Thrombolysis C↓ C B↑ C↓ Domain 4: Specialist assessments B↓ B A↑ B↓ Domain 5: Occupational therapy C↓ C C A↑↑ Domain 6: Physiotherapy B B B B Domain 7: Speech and language C D↓ C↑ C therapy Domain 8: Multi-disciplinary team C↓ C B↑ B working Domain 9: Standards by discharge A↑ A A A Domain 10: Discharge processes A A A A Team-centred total key indicator B C↓ B↑ B level

Dec 16 Apr 17 Aug 17 - Dec 17 - Overall Scores - Mar 17 -Jul 17 Nov 17 Mar 18 SSNAP level B C↓ B↑ B Case ascertainment band A A A A Audit compliance band A B↓ A↑ A Combined total key indicator level B C↓ B↑ B (Source: Royal College of Physicians London, SSNAP audit)

The medicine directorate quality improvement (QUIP) team had developed an action plan to address the SSNAP audit findings with the aim of improving service for patients. For example, recruiting more occupational therapists (OT) and physiotherapists (PT) to address shortcomings in the access to allied health professionals for stroke patients. At the time of inspection, the service was trialling seven day working for PTs and expected to roll this out before the end of 2019. The QUIP actions to address the SSNAP audit findings from December 2018 (Overall rating B), were: Clinical Educator to develop education and awareness plan and workforce plan being developed for 2019/20. There was no detail in the action plan as to how these steps would be completed.

Lung Cancer Audit The table below summarises the trust’s performance in the 2017 National Lung Cancer Audit. Metrics Trust Comparison to Meets (Audit measures) performance other Trusts national standard? Crude proportion of patients seen by a cancer nurse specialist 65.6% Not applicable 

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(Access to a cancer nurse specialist is associated with increased receipt of anticancer treatment) Case-mix adjusted one-year survival rate Within expected No current (Adjusted scores take into account 38.0% range standard the differences in the case-mix of patients treated) Case-mix adjusted percentage of patients with Non Small Cell Lung Cancer (NSCLC) receiving surgery (Surgery remains the preferred Within expected 14.0% treatment for early-stage lung cancer; range  adjusted scores take into account the differences in the case-mix of patients seen) Case-mix adjusted percentage of fit patients with advanced NSCLC receiving systemic anti-cancer treatment (For fitter patients with incurable Within expected NSCLC anti-cancer treatment is 69.2% range ✓ known to extend life expectancy and improve quality of life; adjusted scores take into account the differences in the case-mix of patients seen) Case-mix adjusted percentage of patients with Small Cell Lung Cancer (SCLC) receiving chemotherapy (SCLC tumours are sensitive to Within expected 78.0% chemotherapy which can improve range ✓ survival and quality of life; adjusted scores take into account the differences in the case-mix of patients seen) (Source: National Lung Cancer Audit) The service had not developed a robust and detailed action plan in response to audit findings (2017) despite two areas of lung cancer care not meeting national standard. The action plan simply stated the service would continue to take part in the audit to indicate areas of strength and weakness and that the service was continuously striving to perform the very best they could as a tumour site.

National Audit of Inpatient Falls 2017 Norfolk and Norwich University Hospital

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The table below summarises Norfolk and Norwich University Hospital’s performance in the 2017 National Audit of Inpatient Falls. The audit reports on the extent to which key indicators were met and grades performance as red (less than 50% of patients received the assessment/intervention), amber (between 50% and 79% of patients received the assessment/intervention) and green (more than 80% of patients received the assessment/intervention). Meets national Metrics Hospital Audit’s Rating aspirational (Audit measures) performance standard? Does the trust have a multidisciplinary working group for falls prevention where data on No N/A  falls are discussed at most or all the meetings? Crude proportion of patients who had a vision assessment (if applicable) (Having a vision 60.0% Amber  assessment is indicative of good practice in falls prevention) Crude proportion of patients who had a lying and standing blood pressure assessment (if applicable) 25.0% Red  (Having a lying and standing blood pressure assessment is indicative of good practice in falls prevention) Crude proportion of patients assessed for the presence or absence of delirium (if applicable) 50.0% Amber (Having an assessment for delirium  is indicative of good practice in falls prevention) Crude proportion of patients with a call bell in reach (if applicable) (Having a call bell in reach is an 82.8% Green  important environmental factor that may impact on the risk of falls) (Source: National Audit of Inpatient Falls) Nursing staff recorded the number of patient falls per month on a white board at the entry to each ward. Nursing staff ensured patient calls bells were within patient reach during intentional rounding to try to reduce the number of patients mobilising without help. Ward managers and specialty leads discussed the number of patient falls per month as part of monthly discussions of the ward dashboard. We asked the trust for the action plan developed in response to the audit findings (2017) but they did not supply this. This meant we could not be assured the service was using audit data to improve patient outcomes.

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Chronic Obstructive Pulmonary Disease Audit Norfolk and Norwich University Hospital The table below summarises Norfolk and Norwich University Hospital’s performance in the 2017 Chronic Obstructive Pulmonary Disease Audit. Metrics Hospital Meets national Audit’s Rating (Audit measures) performance standard? Percentage of patients seen by a member of the respiratory team Better than the within 24hrs of admission? 89.1% national ✓ (Specialist input improves processes aggregate and outcomes for COPD patients) Percentage of patients receiving oxygen in which this was prescribed to a stipulated target oxygen saturation (SpO2) range Better than the (of 88-92% or 94-98%) 100.0% national (Inappropriate administration of ✓ aggregate oxygen is associated with an increased risk of respiratory acidosis, the requirement for assisted ventilation, and death) Percentage of patients receiving non-invasive ventilation (NIV) within the first 24 hours of arrival Worse than the who do so within 3 hours of 16.7% national arrival  aggregate (NIV is an evidence-based intervention that halves the mortality if applied early in the admission) Percentage of documented current smokers prescribed smoking-cessation Better than the pharmacotherapy 28.0% national  (Smoking cessation is one of the few aggregate interventions that can alter the trajectory of COPD) Percentage of patients for whom a British Thoracic Society, or equivalent, discharge bundle was Better than the completed for the admission 86.1% national ✓ (Completion of a discharge bundle aggregate improves readmission rates and integration of care) Percentage of patients with Better than the spirometry confirming FEV1/FVC 42.0% national ratio <0.7 recorded in case file  aggregate

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(A diagnosis of COPD cannot be made without confirmatory spirometry and the whole pathway is in doubt) (Source: Chronic Obstructive Pulmonary Disease Audit) The service provided us with an action plan to address the audit findings (September 2018 to February 2019). The action plan did not have named persons responsible for the monitoring of the completion of each action and was a list of tasks to be completed with no definitive time frame. Tasks to be completed included; • introduce ‘Toolkits’ for RN team and all wards to show examples of nicotine replacement therapy (NRT). • develop a Patient Group Directive (PGD) for core NRT products to increase awareness of the use of, and availability and timeliness of NRT provision in Hospital. • educate ward nurses working within respiratory medicine regarding Smokefree referrals and use of NRT on a Respiratory Study Day planned for April 2019.

National Audit of Dementia Norfolk and Norwich University Hospital The table below summarises Norfolk and Norwich University Hospital’s performance in the 2017 National Audit of Dementia.

Metrics Hospital Meets national Audit’s Rating (Audit measures) performance standard? Percentage of carers rating overall care received by the person cared for in hospital as Excellent or Very Good (A key aim of the audit was to No current 67.7% Similar collect feedback from carers to ask standard them to rate the care that was received by the person they care for while in hospital) Percentage of staff responding “always” or “most of the time” to the question “Is your ward/ service able to respond to the needs of people with dementia as No current they arise?” 88.0% Better standard (This measure could reflect on staff perception of adequate staffing and/or training available to meet the needs of people with dementia in hospital) Mental state assessment carried No current 24.0% Worse out upon or during admission for standard

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 115 recent changes or fluctuation in behaviour that may indicate the presence of delirium (Delirium is five times more likely to affect people with dementia, who should have an initial assessment for any possible signs, followed by a full clinical assessment if necessary) Multi-disciplinary team involvement in discussion of discharge (Timely coordination and adequate No current discharge planning is essential to 95.2% Better standard limit potential delays in dementia patients returning to their place of residence and avoid prolonged admission) (Source: National Audit of Dementia) The dementia audit (January 2018) showed improvement on the previous audit (2016/2017). The trust acted on the audit findings in the form of employing an associate physician (in training) completing a service improvement project to improve the use of the identification flower wristband and the “This is me” booklet. A dementia support nurse had also been recruited. One member of nursing staff on Elsing ward described calling on the dementia support nurse to help with a patient and that the role was useful.

Competent staff The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service. However, compliance with annual appraisal varied across the service. The trust had recently introduced a new process and format for staff appraisals. The staff we spoke with who had completed the new process spoke positively about it and told us it had been useful, better than the old process and they preferred the forms. Information provided by the trust showed Elsing, Earsham, Kilverstone ward and the Jack Prior unit all met or exceeded the trust target of 90% compliance at December 2018. At the time of inspection, Langley ward and the acute medical unit ladies (AMUK) were also exceeding the trust target. Ward managers displayed appraisal compliance rates on a white board at the ward entrance. Not all the wards we visited met the trust appraisal target but were showing an improving trend. For example, Guist ward, was 53% in November 2018 and at the time of inspection this had improved to 63%, Mulbarton ward was 66% and this had improved to 73%.

Multidisciplinary working

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Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care. All the patient medical notes we reviewed evidenced multidisciplinary team (MDT) input into patient care within 24hours of the patient being admitted to a ward. Different specialty staff used different colour stickers in patient medical notes to clearly identify their input. For example, dietician, occupational therapist (OT), physiotherapist (PT) and speech and language therapist (SALT) each used a different colour. Mulbarton ward had ward based PTs who were involved in end of life care planning and discharge planning. We observed MDT discussions at the ward “red to green” meetings which ensured a holistic approach to patient care. Red and green days are a visual management system to assist in the identification of wasted time in a patient’s journey. A red day is when a patient receives little or no value adding acute care, a green day is when a patient receives care that progresses them towards discharge. On Dunston ward we spoke with a trust wide pharmacist who visited the ward each day to ensure patients had been prescribed their medication correctly and the ward had enough stock. Ward managers attended a “Timely Tuesday” meeting every Tuesday to discuss those patients who had been medically fit for discharge for more than 21 days. Meetings were multi-disciplinary including social workers, PTs and the discharge team.

Seven-day services The service did not provide seven-day service for all specialities but was trailing moving to seven day, 24 hour service for physiotherapy services. Physiotherapy (PT) staff worked weekend mornings, including on the stroke unit where new patients and patients being discharged were reviewed. One PT described the seven-day programme the trust were trialling with the aim of moving to a 24/7 service by the end of 2019. There was no seven-day occupation therapy (OT) service. The stroke unit had four hours of OT cover on a Saturday but none on a Sunday. Speech and Language Therapy (SALT) did not run a seven-day service. Senior managers were aware of this but there were no plans to change this. Dietician input was available Monday to Friday.

Health promotion People were empowered and supported to manage their own health and independence as far as possible. We observed a health care assistant supporting a patient to the bathroom so they could perform their own personal care. This enabled the patient to retain some independence. Ward staff displayed patient information leaflets and details of support groups available for patients living with long term conditions.

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Posters displayed on many of the wards we visited encouraged staff to support patients to get dressed as part of the end pyjamas paralysis campaign. The campaign aims to encourage patients, wherever possible, to change out of their pyjamas, get up out of bed and move around. Expert Patient Programme information, where patients are given skills to self-manage their health conditions, was displayed throughout the trust.

Consent, Mental Capacity Act and Deprivation of Liberty Safeguards Staff understood how and when to assess whether a patient had the capacity to make decisions about their care. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care. However, they did not always document appropriately or in line with trust policy. Two nursing staff told us they felt that the trust had put a lot of effort into MCA and DoLS training. The trust displayed posters detailing processes for staff to follow around MCA in all wards we visited. All the nursing staff we spoke with about MCA and DoLS were knowledgeable and could describe the trust process for assessing patient mental capacity. Nursing staff requested verbal consent before carrying out any patient care. Nursing staff recorded patient consent in the medical notes and used a yellow “best interest decision” sticker where consent had not been given. However, staff did not consistently follow the trust policy and procedures when a patient could not give consent. The trust policy titled “Trust Policy for Assessment of Mental Capacity and Decision Making for People Lacking Capacity”, due for review January 2020, clearly described the paper work nursing and medical staff needed to complete and how a copy of the records should be stored in the patient care record. We reviewed five sets of patient medical records relating to patients who were suspected of lacking capacity, four records on Elsing ward and one record on Heydon ward. Nursing and medical staff on Elsing ward had completed MCA documentation fully and appropriately in two out of four records. Nursing staff stated that mental capacity assessments had been completed in the other two records but were unable to locate the document which meant this was not formally documented in the patient record. The trust had a policy for completing DoLS applications, “Avoiding Unlawful Deprivation of Liberty (DoLS)”, due for review April 2019. Nursing and medical staff on Elsing ward had completed DoLS documentation fully and appropriately in two out of four records. Two patient records contained expired DoLS applications which had not been extended. Nursing staff were confused around whether or not one of the patients was still being treated under the DoLS safeguards. This meant that by not having the correct documentation then the patient was being unlawfully deprived of liberty even if this was clinically appropriate. On Heydon ward, nursing and medical staff had adhered to the trust policy and process in the one patient medical record we were able to review.

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The trust set a target of 90% for completion of Mental Capacity Act (MCA) and Deprivation of Liberty training. A breakdown of compliance for Mental Capacity Act (MCA) and Deprivation of Liberty Safeguarding (DoLS) courses at September 2018 for qualified nursing staff in medicine is shown below:

Number of Number of eligible staff trained staff Completion Trust Met Name of course (YTD) (YTD) rate Target (Yes/No) Deprivation of Liberty Safeguards 561 667 84% 90% No Mental Capacity Act Level 1 559 666 84% 90% No

Qualified nursing staff did not meet the trust training target for either of the training modules relating to the Mental Capacity Act (MCA) or Deprivation of Liberty (DoLS). At the time of inspection, there were inconsistencies with training compliance. Kimberley, Langley, Loddon and Elsing ward nursing staff met the trust target for MCA and DoLS training. Mulbarton had the lowest compliance at 56%. A breakdown of compliance for Mental Capacity Act (MCA) and Deprivation of Liberty Safeguarding (DoLS) courses at September 2018 for medical and dental staff in medicine is shown below:

Number of Number of eligible staff trained staff Completion Trust Met Name of course (YTD) (YTD) rate Target (Yes/No) Mental Capacity Act Level 1 163 261 62% 90% No Deprivation of Liberty Safeguards 163 261 62% 90% No

Medical staff did not meet the trust training target for either of the training modules relating to the Mental Capacity Act (MCA) or Deprivation of Liberty (DoLS). (Source: Routine Provider Information Request (RPIR) – Training tab) The trust wide MCA and DoLS lead had carried out an audit of MCA and DoLS documentation (November 2018). The auditor looked at five cases, in one case nursing staff had not evidenced mental capacity assessment and in another case the DoLS had expired without an extension being applied for. The auditor had not developed an action plan to address issues identified by the audit. A re-audit was scheduled for March 2019.

Is the service caring? Compassionate care Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. All the relatives and carers we spoke with spoke positively about the nursing care their relative had received. 20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 119

Ward staff displayed “thank you” cards, sent by previous patients and their relatives, in communal areas. Cards referenced caring staff showing kindness. The Friends and Family Test response rate for medicine at the trust was 15% which was worse than the England average of 25% from October 2017 to September 2018. A breakdown of FFT performance by ward for medical wards at Norfolk and Norwich University Hospital over the same period is shown below.

1. The total responses exclude all responses in months where there were less than five responses at a particular ward (shown as gaps in the data above), as well as wards where there were less than 100 responses in total over the 12-month period. 2. Sorted by total response. 3. The formatting above is conditional formatting which colours cells on a grading from highest to lowest, to aid in seeing quickly where scores are high or low. Colours do not imply the passing or failing of any national standard. (Source: NHS England Friends and Family Test) Ward managers displayed friends and family test scores on a white board at the entrance to each ward. For December 2018 Elsing, Mulbarton, Kimberley ward and the acute medical unit Holt ward all scored 100%, Earsham ward scored 89% and Langley ward 87%. We were not able to ascertain the response rate. Staff closed curtains around patient bed spaces when providing care. Staff wishing to enter the bed space called out to introduce themselves and asked if it was ok to come in before entering. Staff gave patients shawls and blankets to put over their legs when they sat out in chairs. This protected the patient’s dignity and modesty.

Emotional support Staff provided emotional support to patients to minimise their distress. Patients had access to a social worker and a counselling service for emotional support. A clinical psychologist was based on the stroke unit to assist patients in the acute phase of their illness. Staff signposted patients for continued support such as that provided by the Stroke Association. Ward staff could access the trust wide mental health team for any patients they had concerns about 24 hours per day seven days per week. On Elsing ward, we saw a therapy dog. The dog handler explained how the patients enjoyed fussing the dog and looked forward to seeing it and found it relaxing. Staff regularly welcomed a volunteer into the ward to play the piano and the patients reported enjoying listening to the music.

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Staff had access to a trust wide, 24-hour seven-day multifaith chaplaincy service to meet the religious needs of those patients who requested it.

Understanding and involvement of patients and those close to them Staff involved patients and those close to them in decisions about their care and treatment. All the patients and relatives or careers we spoke with told us staff had provided them and their family member with enough information about their care and treatment. We observed an HCA explaining a blood pressure reading to a patient and providing reassurance that this was in acceptable range. Nursing and medical staff placed a green sticker in the patient’s medical notes so that it was clearly visible when there had been discussions with family. This was evidenced in the medical records we reviewed. Nursing staff in the endoscopy unit gave patients discharge information packs after their procedures. Packs contained advice and information about what to expect, possible side effects and a summary of the procedure they had undergone.

Is the service responsive? Service delivery to meet the needs of local people The trust planned and provided services in a way that met the needs of local people. The service had continued to be expanded, with investment in additional buildings, and development of specific patient pathways to ensure that services reflected the needs of the local people. The trust had recently opened the Quadram Institute which was a purpose-built centre for diagnostic and therapeutic endoscopy, colonoscopy and flexible sigmoidoscopy. The centre was opened in December 2018 and had eight functioning endoscopy rooms and was open for patients from 8am to 6pm five days per week. The trust had opened an older people’s emergency department (OPED). This service was available to elderly and frail patients presenting at the emergency department (ED) from the community. The service was planning to move dialysis services to an offsite location under a managed service contract with an external dialysis provider. This was due to go ahead by December 2019. The trust had significantly developed its primary percutaneous coronary intervention (PPCI) service to offer a very responsive pathway to patients. The service worked closely with the local ambulance service which meant potential patients were identified by paramedics who alerted the service. A senior doctor or nurse met patients at the door of the ED, obtained consent and medical history and then immediately the patient was transferred into the catheter lab, when available. The service had developed a fractured neck of femur (NOF) pathway. The divisional leads told us the pathway improved the process for treating those patients who presented in the ED. We did not see any data to evidence this. The service Acute Medical Unit (AMU) was separated into two sections, AMU K (for Men) and AMU H (for Women). AMU provided rapid assessment, diagnosis, stabilisation, observation and

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 121 early treatment of patients who were admitted by the emergency department or by GPs. Patients could stay here for up to 72 hours prior to being discharged or admitted to a ward. The service provided ambulatory care in the AMU. This was nine trolley spaces. The ambulatory care trolley spaces were not ring-fenced and were regularly used as inpatient bed spaces during periods of escalation. This meant that the ambulatory service was regularly suspended. In the endoscopy unit staff updated electronic welcome screens to keep patients informed of any delays.

Meeting people’s individual needs The service took account of patients’ individual needs and had taken steps to identify and meet the information and communication needs of people with a disability, those living with dementia or sensory loss. These included the use of symbols, colour and translation services. The trust had a dementia strategy and a care pathway and policy for the care of patients who had learning disabilities or were living with autism. Staff identified patients living with dementia by a forget-me-not symbol displayed outside of their room and where appropriate on patient records. Staff also used a wristband for some patients to promote staff awareness that the patient was living with dementia. Patients living with dementia and those who had suffered stroke had “This is me” documentation in place. We saw two completed “this is me” booklets. A dementia support team assisted ward staff with expertise in how to care for patients living with dementia. On Kimberley ward, staff had decorated the day room to recreate a 1950s sitting room with old fashioned furniture and wall paper, television and radio. On Elsing ward the bays had been colour coded. This was part of making the environment dementia friendly and homely and to assist patients moving around the ward. Staff used a diagram on the room doors and at the bed sides of patients to identify those patients who had specific needs. For example, if they had hearing difficulties, visual impairment or required support with eating among other things. On all the older peoples medicine (OPM) wards patients had access to games and colouring. Staff on acute medical unit AMU (H) ward described how they had set up tables in the middle of the ward so that some patients could have a game of scrabble together. Staff across the service had easy access to bariatric and pressure relieving equipment when required. Staff had access to face to face and telephone translation service for those patients who did not speak English as their first language. Staff could access lip reading and British sign language services if the need arose.

Access and flow The service was introducing new processes and care pathways to try to ensure people have timely access to initial assessment, diagnosis or urgent treatment. The service had developed a fractured neck of femur (NOF) pathway. Staff identified those patients who presented in the emergency department with a fractured NOF quickly, added them to

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 122 the surgery list immediately and patients could begin the process of rehabilitation in a ward specific for the condition. The recently opened older people’s emergency department (OPED), received elderly and frail patients from the community. Older people received a geriatric assessment, input from occupational therapists (OT), physio therapists (PT) and pharmacist within 48 hours. This had reduced the number of elderly patients being inappropriately admitted and enabled the service to reduce the number of OP medical wards to four. The trust told us they had seen a reduction in attendance-to-admittance conversion rate from 31% to 24% due to expanding ambulatory care and providing a comprehensive geriatric assessment for older patients with frailty in the OPED. The service admitted patients from other local hospitals for emergency cardiac intervention (PPCI) which was coordinated via an electronic system. This allowed staff to monitor the arrival of patients from other hospitals and prioritise care and treatment. Medical and nursing staff planned for patient discharge daily at red to green board rounds. Nursing staff worked with discharge planners to ensure speedy patient discharges. The trust held bed meetings three times each day to manage capacity. The on-call executive regularly attended these meetings. Nursing staff arranged for patients waiting for medication or transport prior to going home to wait in the discharge lounge to free up bed spaces. The discharge lounge opened in December 2018, operates seven days a week and can accommodate up to 28 patients at a time in comfortable seats or beds. Consultants had clinical responsibility for their specialty inpatients who were not accommodated in their base ward but were located elsewhere. Such patients are termed ‘outliers’. Registrars reviewed outlier patients daily, this was evidenced in the medical records of three outlier patients. The trust had recently undergone some ward relocations but signage throughout the hospital had not been updated to reflect the changes. This led to some difficulties and confusion when navigating around the hospital. For example, acute medical unit (AMU) was now located on level one but wall signs still stated level two.

Trust Level From August 2017 to July 2018 the average length of stay for medical elective patients at the trust was 3.7 days, which is lower than the England average of 6.0 days. For medical non-elective patients, the average length of stay was 6.5 days, which is similar to the England average of 6.3 days. Average length of stay for elective specialties: • Average length of stay for elective patients in cardiology is lower than the England average. • Average length of stay for elective patients in gastroenterology is higher than the England average. • Average length of stay for elective patients in clinical haematology is lower than the England average.

Elective Average Length of Stay – Trust Level

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Note: Top three specialties for specific trust based on count of activity.

Average length of stay for non-elective specialties: • Average length of stay for elective patients in general medicine is higher than the England average. • Average length of stay for elective patients in geriatric medicine is lower than the England average. • Average length of stay for elective patients in cardiology is similar to the England average.

Non-Elective Average Length of Stay – Trust Level

Note: Top three specialties for specific trust based on count of activity.

Norfolk and Norwich University Hospital From August 2017 to July 2018 the average length of stay for medical elective patients at Norfolk and Norwich University Hospital was 3.7 days, which is lower than England average of 6.0 days. For medical non-elective patients, the average length of stay was 6.5 days, which is similar to the England average of 6.3 days. Average length of stay for elective specialties: • Average length of stay for elective patients in cardiology is lower than the England average. • Average length of stay for elective patients in gastroenterology is higher than the England average. • Average length of stay for elective patients in clinical haematology is lower than the England average.

Elective Average Length of Stay - Norfolk and Norwich University Hospital

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Note: Top three specialties for specific site based on count of activity.

Average length of stay for non-elective specialties: • Average length of stay for non-elective patients in general medicine is higher than the England average. • Average length of stay for non-elective patients in geriatric medicine is lower than the England average. • Average length of stay for non-elective patients in cardiology is similar to the England average.

Non-Elective Average Length of Stay - Norfolk and Norwich University Hospital

Note: Top three specialties for specific site based on count of activity.

Cromer Hospital From August 2017 to July 2018 the average length of stay for medical elective patients at Cromer Hospital was 1.3 days, which is lower than England average of 6.0 days. Average length of stay for elective specialties: • Average length of stay for elective patients in clinical oncology is lower than the England average. • Average length of stay for elective patients in pain management is lower than the England average. • Average length of stay for elective patients in nephrology is lower than the England average.

Elective Average Length of Stay - Cromer Hospital

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Note: Top three specialties for specific site based on count of activity.

Non-elective Average Length of Stay - Cromer Hospital Cromer hospital only has elective medical activity so there are no non-elective lengths of stay. (Source: Hospital Episode Statistics)

Referral to treatment (percentage within 18 weeks) - admitted performance From October 2017 to September 2018 the trust’s referral to treatment time (RTT) for admitted pathways for medicine was worse than the England average. Over the 12-month period RTT performance at the trust has ranged from 76.8% to 86.5% compared to the England average which has ranged from 88.0% to 90.0%. In September 2018, 76.8% of admitted pathways at the trust were completed within 18 weeks, compared to the England average of 88.1%.

(Source: NHS England)

Referral to treatment (percentage within 18 weeks) – by specialty Four specialties were above the England average for admitted RTT (percentage within 18 weeks). Specialty grouping Result England average General medicine 100.0% 96.7% Geriatric medicine 100.0% 96.9% Rheumatology 99.3% 94.9% Gastroenterology 93.8% 93.6%

Four specialties were below the England average for admitted RTT (percentage within 18 weeks). Specialty grouping Result England average Thoracic medicine 92.7% 93.6%

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Neurology 86.7% 90.9% Dermatology 81.2% 81.9% Cardiology 72.1% 81.6% (Source: NHS England) Six specialties were close to, or better than, the England average for referral to treatment (RTT). Two specialities, Cardiology and Neurology were significantly below this. Data provided by the trust showed all the wards we visited had regular patient bed moves. In January 2019, Guist reported the highest number of moves at 69 and Elsing reported the lowest at 20 moves. For the period September 2018 to January 2019 Guist and Langley wards reported the greatest number of moves, 359 and 377 respectively. Elsing reported the lowest number at 52 moves. The trust were recording all bed moves however the system did not allow for the data to be broken down to easily identify when moves had been clinically justified, for example if a patient deteriorated and was transferred to critical care. The only way this could be tracked was by looking at individual patient records. The trust was unable to define which patient bed moves were for clinical and non-clinical reasons. From October 2017 to September 2018, there were 2,458 patients moving wards at night within medicine. The medical wards with the highest number of patients moving wards at night are: • Coronary Care Unit: 362 ward moves at night • Heydon Neuroscience Ward: 349 ward moves at night • Langley Ward: 215 Ward moves at night • Mattishall Ward: 200 ward moves at night (Source: Routine Provider Information Request (RPIR) – Moves at night tab)

Learning from complaints and concerns The service learned lessons from complaints and concerns and took action to improve the quality of care patients received. From October 2017 to October 2018 there were 239 complaints about medical care. The trust took an average of 31 days to investigate and close complaints, and 35.3% of the complaints were closed within 25 days. This is not in line with their complaints policy, which states that more than 50% of complaints should be closed within 25 days. All 239 complaints related to medical care at Norfolk and Norwich University Hospital. A table of complaint subjects can be found below. Number of Percentage of Core service complaints total complaints Communications 58 24.3% Clinical Treatment - General Medical 49 20.5% Patient Care including Nutrition/Hydration 30 12.6% Admission, Discharge and Transfers 27 11.3% Privacy, Dignity and Wellbeing 18 7.5% Appointments including delays and cancellations 9 3.8% Facilities 7 2.9% Prescribing Errors 6 2.5% Trust Administration 5 2.1%

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Clinical Treatment - Surgical 5 2.1% End of Life Care 5 2.1% Values and Behaviours (Staff) 5 2.1% Other 3 1.3% Access to Treatment or Drugs 2 0.8% Waiting Times 2 0.8% Consent 2 0.8% Clinical Treatment - Oncology 2 0.8% Transport (Ambulances Only) 1 0.4% Restraint 1 0.4% Integrated Care 1 0.4% Clinical Treatment - Pathology 1 0.4% Total 239 100.0% (Source: Routine Provider Information Request (RPIR) – Complaints tab) Ward managers displayed the number of complaints received during the previous month on a white board at the ward entrance. Nursing staff discussed complaints and outcomes at team meetings. This was evidenced by meeting minutes stored in the ward “green folder” on Kilverstone ward dated November 2018. On one ward we spoke with a nurse who was aware of a recent complaint and what had been done to address it and learn from it. Minutes of the stroke directorate meeting (November 2018) confirmed staff shared learning from incidents. One staff member on Mulbarton ward, described how the ward manager had introduced a noise at night champion in response to a complaint about noise on the ward at night. This demonstrated acting on complaints. All the patients and relatives we spoke with knew how to make a complaint. Ward staff displayed patient information leaflets on the reception desk regarding making complaint.

Number of compliments made to the trust From October 2017 to September 2018 there were 88 compliments within medicine. A breakdown by ward can be found below. Ward managers shared compliments with staff during team meetings. We saw evidence of this in the Dunston team meeting minutes (January 2019) filed in the ward green folder. Percentage of Number of Ward name/area total compliments compliments Gastroenterology Unit 16 18.2% Kilverstone Ward 8 9.1% General Medical Day Unit 8 9.1% Hethel Ward 6 6.8% Weybourne Day Unit 6 6.8% Coronary Care Unit 4 4.5% Audiology 4 4.5% Stroke 4 4.5% Mattishall Ward 3 3.4% Oncology 3 3.4%

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Neurology Department 3 3.4% Heydon Neurology 3 3.4% Rheumatology Day Unit 3 3.4% Brundall Ward 3 3.4% Mulbarton Ward 2 2.3% Guist Ward 2 2.3% Langley Ward 2 2.3% Respiratory Medicine Administration 1 1.1% Heydon Stroke 1 1.1% Loddon Ward 1 1.1% Kimberley Ward 1 1.1% Dunston Ward 1 1.1% Elsing Ward 1 1.1% Holt Ward 1 1.1% Jack Pryor Unit 1 1.1% Total 88 100.0% (Source: Routine Provider Information Request (RPIR) – Compliments tab)

Is the service well-led? Leadership Managers at all levels in the trust had the right skills and abilities to run a service. The medical division was led by a triumvirate consisting of a chief of division (COD), divisional nurse director (DND) and divisional operations director (DOD). The COD had been in post for four years, the DND for 15 months and the DOD for approximately one week so were still a relatively new team. All three had held lead roles previously and were experienced leaders. The COD had also undertaken training in leadership and had attended the Kings Fund leadership course. The divisional leads told us that they were being given increasing autonomy with a “just do it” attitude from the senior leadership team to manage their own strategy and the business of the division. All three leads felt the senior triumvirate was a strong executive team. Each of the 14 medical specialities were led by a triumvirate of a specialty operations lead, service director and matron. The triumvirate reported to the medical division leads. All the staff we spoke with were positive about the senior leadership team and, in particular, the visibility of the chief nurse, on the wards. Ward managers told us the chief nurse was proactive, supportive and approachable. Ward staff spoke positively about their local leaders saying they were supportive. Ward managers and service leads responded to concerns we raised during the inspection. For example, implementing reflective practice for a medical staff member who had not acted in line with trust policy.

Vision and strategy The trust had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups representing the local community.

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The divisional triumvirate of the chief of division, deputy nurse director and the director of division described the strategy for workforce recruiting medical staff and nursing staff of all grades, ward by ward, based on ward need. The division leaders had a clear strategy for the development of the services, recruitment and managing capacity by developing different ways of working. For example, development of the ambulatory care service, fractured neck of femur pathway and older peoples’ emergency department had led to a reduction in admissions of patients aged over 80 years of age. Staff we spoke with on the wards were unaware of any local vision or strategy held by the trust in relation to the medical division but were aware of the Norfolk and Norwich University Hospitals five-year strategy. This was displayed on some of the wards we visited. Staff we spoke with knew the PRIDE values of the trust and we saw these displayed throughout the wards we visited. PRIDE stood for people, respect, integrity, dedication and excellence. All the staff we spoke with felt staff lived by the values.

Culture Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. All the staff we spoke with told us they felt valued and respected by their colleagues and line managers. All staff we spoke with told us that they enjoyed working for the trust and that there was a positive culture within the service. We observed multidisciplinary working between different staff groups including nursing staff, allied health professionals, catering, housekeeping and medical teams. It was clear that there were strong working relationships, and respect for team members skills, from junior staff through to the most senior leaders. Staff spoke positively about being able to raise concerns without fear of reprisals and told us that the culture of the hospital felt much better than at our previous inspection.

Governance The trust used a systematic approach to improving the quality of its services and patient care. The service had recently undertaken a governance review and introduced monthly divisional governance meetings. Each specialty held monthly clinical governance meetings. Meeting minutes (14 November 2018) recorded agenda items included incidents, risks, quality, patient experience, compliments and complaints and audits among other things. Speciality monthly clinical governance group reported to the divisional clinical governance group monthly meeting. The divisional clinical governance group reported to the board. Governance related information was cascaded down to staff through team meetings and team briefs from senior nurses. Team meeting minutes dated 20 September 2018 demonstrated nursing staff discussed incidents, audit findings, ward dashboard, mandatory training and staffing among other things.

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Management of risk, issues and performance The trust had systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. However, management processes did not ensure service performance improvement. The service had arrangements for identifying, recording and managing risks and issues and developing mitigating actions. The medicine service risk register had 36 risks open. Six of these remained open from 2012. While risks were being reviewed they were not being actioned to reduce the level of risk for example, the service had identified the need to introduce tissue viability nurses (TVN) as a 24 hour service but this had not happened. Each risk was rated and had a named responsible person assigned to oversee it. The service leads described how they reviewed risks at governance meetings on a monthly or six-monthly basis depending on the severity of the risk. This was evidenced on the risk register. Scrutiny of the risk register took place at clinical governance meetings for each specialty and at divisional level. The service leaders had agreement between the recorded risks on the service risk register and what managers told us was on their worry list. Integrated performance reports were produced on a monthly basis for each division to manage risk, issues and performance. Reports included an update on progress against the five-year strategy, data on performance against treatment times and waiting lists, activity levels, a review of risks and action logs, a workforce summary, and a review of financial performance. The reports also included a review of quality and safety through a review of incidents, complaints, and infection control. Medicine division nursing leads generated a nursing dashboard monthly with key performance and quality indicators for all wards in the division. This was followed up with action plans where necessary. We were not assured action plans were detailed or robust. The service took part in local audits and developed action plans to improve quality based on audit findings. The trust wide audit team shared national audit compliance reports at divisional governance meetings. The action plans we saw were not robust and lacked detail. The divisional leads were aware the service was not meeting mandatory training and appraisal compliance targets. The trust stated the division was now focusing on its governance processes to ensure learning from incidents, and improving mandatory training and appraisal.

Information management The trust collected, analysed, managed and used information to support all its activities, using secure electronic systems with security safeguards. However, the information technology (IT) systems did not support easy monitoring and management of patient information. Nursing staff referred to electronic screens showing information about each bed currently occupied displayed in each ward. However, ward staff were not able to update the screen directly but instead had to inform the hospital control centre. This meant that the screens did not always display the most up to date information. Medical staff referred to patient information which they printed off the electronic patient administration system (PAS). This was more detailed than the ward system. The trust told us their long-term strategy was for an Electronic Patient Record (EPRs) to be implemented along with an

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 131 electronic document management system (EDMS). The current PAS system only provided a single interface with some of the IT systems. Service leads were not able to update the service risk register in a timely manner but relied on a member of administrative staff who had been on long term sickness absence. Staff had access to policies, standard operating procedures and patient information leaflets electronically through the document pages on the trust intranet. Staff confirmed that this ensured that information was easily accessible and up to date. Staff had received training on data protection and were aware of the associated legalities.

Engagement The trust engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively. Patient feedback was by the friends and family test (FFT), through the Patient Advice and Liaison service (PALS) and through “You said we did” comments. Some wards, including Elsing ward, had ward newsletters available for patients, relatives and staff. This kept people informed about issues on the ward. We saw “you said we did” notices in some of the wards we visited. One said, “not enough staff” the ward response was “we have spoken with the chief nurse and reviewed the staffing level and we are going to recruit more staff”. This showed the service acted on patient feedback. Ward meeting minutes stored in the ward “green folder” showed that wards held regular ward meetings. Ward managers said that it was not always easy to arrange meetings and a number had developed other ways of communicating such as through newsletters, bulletin boards or briefings before the start of a shift. The executive team held a number of listening events so that staff could voice concerns, ask questions or offer ideas for the development of services or change to working practices. Staff said that the senior leadership team held open forums on a regular basis, such as the bi- monthly viewpoint sessions with the chief executive, and sent out regular email updates. Staff in the endoscopy unit used an “Idea of the month suggestion box” to make service improvement suggestions. Staff in the acute medical unit (AMU) had a kindness wall in the staff only area. This was a wall covered in sticky notes each containing a kind message. Nursing staff dedicated them to colleagues. The medical lead gave examples of where staff had raised ideas to improve the service which had either been introduced, for example the computer guided biopsy using bronchoscope, or were being worked up, for example the chemotherapy at home model.

Learning, continuous improvement and innovation The trust was committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation.

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The oncology service were trailing a chemotherapy at home service which would generate an income and reduce the number of patients attending the hospital while increasing the number of patients receiving chemotherapy. The service had supported a group of nursing staff from the oncology service to visit a leading cancer hospital to see other service models and share learning. The physiotherapy team on Mulbarton ward had introduced a method of identifying patients who were at risk of spinal compression injuries due to unstable spine conditions. This was a quality improvement which was in the process of being audited with outcomes due at the end of February 2019. The service had recently been part of a pressure ulcer collaborative and developed a virtual reality goggles head set for virtual reality training. Staff affectionately referred to them as “Ginty’s goggles” after the tissue viability nurse (TVN) who was part of their development. The work won a National Patient Safety Collaborative award 2018. The service had recently (September 2018) introduced computer guided biopsy using endobronchial ultrasound (EBUS). This was a process which enabled medical staff to collect lung samples (biopsies) during a bronchoscope. This speeded up the process for the diagnosis of lung cancer.

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Surgery

Facts and data about this service The trust offers a range of general and tertiary surgical services covering general surgery, urology, trauma and orthopaedics, ear nose and throat (ENT), ophthalmology, oral surgery, plastic surgery, thoracic surgery, vascular surgery and pain management. Many specialties run a hub and spoke service, with complex surgery performed at Norfolk and Norwich University Hospital (NNUH). The surgery service has seven inpatient wards, with 237 beds, for elective and non-elective patients. There are a further 20 beds for non-elective patients on Easton ward, the emergency assessment unit (EAUS). The department has access to 29 theatres (six in the day procedure unit (DPU), 17 in the main theatre complex, two obstetric theatres, two ophthalmic theatres, one Vanguard theatre and one at Cromer Hospital). Elective surgery is provided from Monday to Saturday. There are three emergency theatres which run every day, two of which provide 24 hour a day care, with the additional one covering from 7.30am to 2am daily. All elective patients are assessed pre-operatively by nurses in the pre-assessment unit and, where appropriate, by a consultant anaesthetist. Patients are seen again on the pre-assessment unit for final pre-operative checks. The orthopaedic department specialises in major joint revision surgery, pelvic reconstruction surgery, spinal surgery and paediatric surgery. The trust has a supra-regional cancer status for penile cancer and is the regional cancer centre for head and neck cancer. The trust also has a regional diagnostic centre for sarcoma as well as acting as the regional centre for vascular surgery. (Source: Routine Provider Information Request (RPIR) – Context acute) The trust had 46,908 surgical admissions from August 2017 to July 2018. Emergency admissions accounted for 16,721 (35.6%), 22,601 (48.2%) were day case, and the remaining 7,586 (16.2%) were elective. (Source: Hospital Episode Statistics) Our inspection of Norfolk and Norwich Hospital was announced. Prior to our inspection we reviewed data we held about the service along with information we requested from the trust. During the inspection we spoke with 46 of staff including doctors, nurses, therapists, health care assistants and non-clinical staff. We spoke with 11 patients and their relatives, reviewed 14 patient records and considered other pieces of information and evidence to come to our judgement and ratings. We visited 10 clinical areas including wards, theatres, day procedure unit and interventional radiology. At our last inspection between October 2017 and March 2018 surgery was rated inadequate overall with safe and well led rated inadequate, responsive rated requires improvement and effective and caring rated good.

Is the service safe? By safe, we mean people are protected from abuse* and avoidable harm.

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*Abuse can be physical, sexual, mental or psychological, financial, neglect, institutional or discriminatory abuse. Mandatory training The service provided mandatory training in key skills to all staff but not everyone completed it. Training rates were variable with medical staff being below trust target for mandatory training. Medical staff did not meet mandatory training targets in safeguarding and nurses’ resuscitation training was 56% and basic life support was 69%. Mandatory training was delivered by both E-Learning and face to face class room sessions. There was a range of subjects covered by mandatory training including basic life support, safeguarding, infection prevention and control and medicines management among others. There had been some improvement in mandatory training rates since our last inspection in 2018, particularly for registered nursing staff and allied health professionals, although not all subjects met the 90% trust target. Mandatory training rates for medical staff remained below trust target as it was at our last inspection.

Mandatory training completion rates The trust set a target of 90% for completion of mandatory training. In surgery the 90% target was met for two of the 13 mandatory training modules for which qualified nursing staff were eligible. A breakdown of compliance for mandatory training courses at September 2018 at trust level for medical staff in surgery is shown below:

Number Number of of staff eligible trained staff Completion Trust Met Name of course (YTD) (YTD) rate Target (Yes/No) Health and Safety (Slips, Trips and Falls) 335 372 90% 90% Yes Blood Transfusion 258 308 84% 90% No Medicine management training 278 337 82% 90% No Infection Prevention (Level 3) 261 347 75% 90% No Fire Safety 271 372 73% 90% No Clinical Record Keeping 256 361 71% 90% No Adult Basic Life Support 235 343 69% 90% No Venous Thromboembolism 235 353 67% 90% No Manual Handling - Object 225 354 64% 90% No Equality and Diversity 234 372 63% 90% No Resuscitation 55 98 56% 90% No Information Governance 197 372 53% 90% No

In surgery the 90% target was met for one of the 12 mandatory training modules for which medical staff were eligible.

Norfolk and Norwich University Hospital

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A breakdown of compliance for mandatory training courses at September 2018 at Norfolk and Norwich University Hospital for qualified nursing staff in surgery is shown below:

Number Number of of staff eligible trained staff Completion Trust Met Name of course (YTD) (YTD) rate Target (Yes/No) Manual Handling - Object 4 4 100% 90% Yes Health and Safety (Slips, Trips and Falls) 455 484 94% 90% Yes Medicine management training 411 464 89% 90% No Fire Safety 427 484 88% 90% No Equality and Diversity 417 484 86% 90% No Blood Transfusion 285 344 83% 90% No Infection Prevention (Level 2) 394 481 82% 90% No Venous Thromboembolism 387 473 82% 90% No Adult Basic Life Support 393 481 82% 90% No Information Governance 394 484 81% 90% No Resuscitation 171 211 81% 90% No Clinical Record Keeping 374 482 78% 90% No Manual Handling - People 368 478 77% 90% No

At Norfolk and Norwich University Hospital the 90% target was met for two of the 12 mandatory training modules for which qualified nursing staff were eligible. The surgical division monitored the compliance with mandatory training at governance meetings attended by senior staff. We found that there were inconsistencies across the division in compliance and that the ability to release staff to attend training varied. On a number of wards senior ward staff told us that it was sometimes difficult to release staff to undertake mandatory training due to staffing and operational pressures on the wards and in other clinical areas. In other areas senior staff told us releasing staff for mandatory training was not difficult. Nursing staff we spoke with confirmed this with some telling us that they had training cancelled to support clinical areas short of staff and others telling us that they had no problems accessing mandatory training. Overall mandatory training compliance on Docking and Coltishall ward was 73%. On Edgefield ward data showed that 97% of staff had completed safeguarding training and 83% had completed medicines management. However, only 73% had completed resuscitation training and 72% completed MCA training. Other wards that were below target for resuscitation training was emergency assessment unit surgery EAUS at 73% and Docking at 73% in December 2018. Information showed that, across the division, 53% of consultants were not fully complaint with all mandatory training requirements, although almost 60% had completed over 90% of required mandatory training. For junior nursing staff 43% were not fully compliant with mandatory training although almost two thirds had completed over 90% of required training. Staff told us that face to face mandatory training was cancelled when the hospital was at a high level of escalation (OPEL 4). In main theatres, overall mandatory training compliance in December 2018 was 86% and an improvement on our last inspection. However, only 72% of staff had completed infection

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 136 prevention and control training, 75% completed adult resuscitation training and 74% paediatric resuscitation. In DPU overall mandatory training was above trust target at 91%.

Cromer Hospital A breakdown of compliance for mandatory training courses at September 2018 at Cromer Hospital for qualified nursing staff in surgery is shown below:

Number Number of of staff eligible trained staff Completion Trust Met Name of course (YTD) (YTD) rate Target (Yes/No) Fire Safety 18 18 100% 90% Yes Infection Prevention (Level 2) 18 18 100% 90% Yes Adult Basic Life Support 18 18 100% 90% Yes Blood Transfusion 8 8 100% 90% Yes Venous Thromboembolism 1 1 100% 90% Yes Clinical Record Keeping 18 18 100% 90% Yes Health and Safety (Slips, Trips and Falls) 18 18 100% 90% Yes Manual Handling - People 17 18 94% 90% Yes Information Governance 16 18 89% 90% No Equality and Diversity 16 18 89% 90% No Medicine management training 16 18 89% 90% No Resuscitation 7 9 78% 90% No

At Cromer Hospital the 90% target was met for eight of the 12 mandatory training modules for which qualified nursing staff were eligible. (Source: Routine Provider Information Request (RPIR) – Training tab) At Cromer staff were now up to date with mandatory training for all core subjects for nursing staff at the time of our inspection.

Safeguarding Safeguarding training completion rates The trust set a target of 90% for completion of safeguarding training.

Trust level In surgery the 90% target was met for three of the five safeguarding training modules for which qualified nursing staff were eligible. A breakdown of compliance for safeguarding training courses at September 2018 at trust level for medical staff in surgery is shown below: Number Number of of eligible staff trained staff Completion Trust Met Name of course (YTD) (YTD) rate Target (Yes/No) Safeguarding Children (Level 2) 235 335 70% 90% No

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Safeguarding Adults (Level 2) 224 354 63% 90% No Safeguarding Children (Level 3) 12 19 63% 90% No PREVENT - Level 3 199 336 59% 90% No

In surgery the 90% target was met for none of the four safeguarding training modules for which medical staff were eligible.

Norfolk and Norwich University Hospital A breakdown of compliance for safeguarding training courses at September 2018 at Norfolk and Norwich University Hospital for qualified nursing staff in surgery is shown below: Number of staff Number of trained eligible Completion Trust Met Name of course (YTD) staff (YTD) rate Target (Yes/No) Safeguarding Children (Level 1) 1 1 100.0% 90% Yes Safeguarding Children (Level 2) 456 468 97.4% 90% Yes Safeguarding Adults (Level 2) 462 483 95.7% 90% Yes PREVENT - Level 3 410 461 88.9% 90% No Safeguarding Children (Level 3) 12 14 85.7% 90% No

At Norfolk and Norwich University Hospital the 90% target was met for three of the five safeguarding training modules for which qualified nursing staff were eligible. A trust wide policy was in place for safeguarding adults and a further policy for children. Staff we spoke with could easily access it. The policy was in date and included information about different types of abuse, female genital mutilation (FGM) as well as Prevent. Prevent is a national government programme aimed at preventing radicalisation in communities. The trust was under target for mandatory training in safeguarding. Whilst nursing staff were just under target for safeguarding training level 3 and Prevent completion, medical staff remained under target for safeguarding training in all of the modules they were required to complete. There were processes in place for safeguarding adults and children. All staff we spoke with were clear about how to make a safeguarding referral or how to escalate concerns within the organisation which included contacting the trust safeguarding team for advice. Staff were able to describe incidents with which they had been involved, how they identified potential safeguarding concerns and the actions they had taken in response to them. They were able to explain different types of abuse and their responsibility in reporting them. Staff spoke highly of the safeguarding team who they said were responsive if staff had a concern or question and they offered clear advice. The team were available out of hours as well as during usual working hours. At our last inspection we found that the recovery area of theatres did not have access to a member of staff who had been trained to safeguarding level 3 for children. This is a requirement under Safeguarding children and young people roles and competencies for health care staff Intercollegiate document 2014. At this inspection we found that recovery staff did have access in theatres to staff with children’s safeguarding level 3 and staff we spoke with knew how to access them.

Cromer Hospital

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A breakdown of compliance for safeguarding training courses at September 2018 at Cromer Hospital for qualified nursing staff in surgery is shown below: Number of staff Number of trained eligible Completion Trust Met Name of course (YTD) staff (YTD) rate Target (Yes/No) PREVENT - Level 3 18 18 100.0% 90% Yes Safeguarding Children (Level 2) 18 18 100.0% 90% Yes Safeguarding Adults (Level 2) 18 18 100.0% 90% Yes Safeguarding Children (Level 3) 0 4 0.0% 90% No

At Cromer Hospital the 90% target was met for three of the four safeguarding training modules for which qualified nursing staff were eligible. Note: The trust was unable to provide site level training data for medical and dental staff working in surgery. (Source: Routine Provider Information Request (RPIR) – Training tab) In the surgery service at Cromer no children under the age of 18 years were cared for. If staff required advice there was access to staff with level three children’s safeguarding training. Staff we spoke with understood their responsibilities for safeguarding and could describe how they would manage a safeguarding concern.

Cleanliness, infection control and hygiene The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection. There were systems and processes in place to ensure standards in cleanliness and infection control. There had been no MRSA bacteraemia’s since our last inspection. There had been nine C. difficile cases in surgery since April 2018 which was below (better than) trajectory. There were adequate hand washing facilities as well as hand hygiene gel positioned around wards and in theatres. Clinical waste was separated appropriately into clinical waste bins. We observed these being regularly collected and removed. General waste bins were available for non-clinical waste. Yellow sharps bins were used for all contaminated sharps such as needles. All those we saw were properly labelled and not overfilled. We saw staff washing their hands appropriately between episodes of care and on entering and leaving clinical areas. Personal protective equipment (PPE) was readily available on wards and in theatres including gloves, aprons, masks and eye shields. We saw staff using PPE correctly and complying with bare arms below the elbow policy. All clinical areas we attended were visibly clean. IPC audits on three wards showed hand washing compliance at 100% and environmental audits at 100%. Green ‘I am clean’ stickers were affixed to equipment that had been decontaminated and was ready for use.

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Cleaning schedules detailed areas that required cleaning and when. These were signed and dated and returned to a supervisor to ensure oversight of the schedule. Infective patients were cared for in side rooms wherever possible. This ensured they could be isolated for their own and others safety and to prevent the risk of spread of infection. We saw that side room doors were kept closed for these patients and that staff entering or leaving the room used and discarded PPE appropriately. When infective patients were discharged, the room was thoroughly decontaminated according to trust policy. At our last inspection we were concerned how infective patients were cohorted and cared for in the interventional radiology unit IRU. At this inspection we found that a new process was in place. Wherever possible infective patients were seen at the end of a list. This was not always possible in the case of emergencies. For those patients, a support worker took the patient directly into the treatment room and then off the unit promptly at the end of the procedure when the patient was stable. This reduced the amount of time the patient spent on the IRU. Records showed that the procedure room was cleaned according to protocol following an infective patient being treated. Staff said this was still not an ideal situation however this would be improved following the opening of a new unit planned for late 2019. In some areas, curtains were fabric and it was not clearly indicated when they had last been changed. Staff told us that curtains were changed every three months or more frequently if required. Clinical areas were found to be complaint with the DHSC Health Building Note 00-09: Infection control in the built environment in relation to floors, wall and easy clean furniture and furnishings. Patients admitted were screened for colonisation with Methicillin Resistant Staphylococcus Aureus (MRSA). Screening was completed as part of pre- admission for elective patients and as soon as possible for emergency admissions. There were clear guidelines for staff to follow in the event a patient was determined to be MRSA positive. Screening compliance was greater than 95% for elective patients. Surgical site infection (SSI) surveillance was completed for vascular, joint replacement and caesarean section patients. Over the last 12 months the Vascular SSI rate was between 3.2% and 10.8% In the last 12 months the caesarean section SSI rate was between 1.7% and 6.4%. In orthopaedic surgery hip, knee and fractured neck of femur was audited. The department reports one quarter's data each year to Public Health England. In quarter two of 2018 there were four infections reported out of 513 cases. One infection was superficial involving a knee replacement. There were three deep infections involving patients that had fractured neck of femurs. This was better than the England average. The trust had engaged with the getting it right first time (GIRFT) programme for surgical site surveillance. At our last inspection we found some staff in theatres to be wearing jewellery and not observing the dress code policy. At this inspection we again observed a senior member of medical staff wearing jewellery in theatres on two occasions. It was no longer trust policy for staff to wear coveralls over theatre scrubs when staff were outside of theatre and masks and hats should not be worn outside of theatres. We did not observe staff wearing masks or hats although we observed seven staff in different parts of the hospital in scrubs.

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At our last inspection we found that escalation areas including DPU were used for infective patients though the environment was not suitable for the care of these patients. At this inspection there had been no infective patients moved to DPU since our last inspection. At Cromer all areas were visibly clean. Cleaning schedules detailed areas to be cleaned and at which frequency. Staff used appropriate PPE and decontaminated their hands between episodes of care. There was adequate PPE available for staff in theatres and on the ward. Fabric curtains were in use on the ward and records showed these were changed three monthly or more often if required. Instruments from theatre were properly stored and returned for decontamination to the Norfolk and Norwich hospital. Single use instruments were disposed of correctly in line with guidance. Instrument sets we checked were in date for sterility. The unit would not admit patients who were MRSA positive on their pre- admission screen. Patients would receive treatment at the Norfolk and Norwich Hospital. Clinical waste in theatres was labelled with the date and case number to allow full traceability.

Environment and equipment The service did not have suitable premises for the care of all patients. The environments in IRU and DPU were sub optimal for patient care. Plans were in place to improve facilities in the interventional radiology unit by the end of 2019. Most clinical areas we visited were suitable and fit for the purpose they were used. However, some escalation areas remained suboptimal for inpatient care due to the lack of natural light. These included DPU and Edgefield ward, where the escalation bed was in use. This room had no natural light as it had been originally designed as a store room. In IRU the ward environment was small and cramped with a single IRU suite and four cubicles. There was limited space and male and female patients were in adjoining cubicles. Senior staff were aware and mixed sex accommodation was noted on the division risk register. There were plans in place to develop a new IRU suite in 2019 which would significantly improve the accommodation for patients. We reviewed over 30 pieces of equipment including blood pressure machines, defibrillators, pumps and air mattresses and found all of them to have be up to date with electrical testing. Equipment that needed servicing was tracked and either returned to the manufacturer for servicing or serviced on site. We checked a range of consumables in clean utility rooms including dressings, needles, syringes and sterilising solutions and found them all to be in date and stored correctly. In theatres there was a clear process for segregation of used (contaminated) and sterile (clean) equipment sets. Used sets were collected several times a day and sent for decontamination. We saw that all unopened theatre sets that we checked were in date for sterility and were stored correctly. At our last inspection we found there was a lack of storage and no process in place for stock review of emergency equipment in the induction and recovery area in the IRU. At this inspection

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 141 we found this had improved. Unnecessary equipment and clutter had been removed. All cupboards were locked and all consumables we checked were in date. At our last inspection we found that resuscitation equipment trolleys and medicines held within these were not tamper proof. At this inspection we found that all the trolleys had been replaced with tamper proof versions. This ensured that equipment and medicines were quickly and easily accessible whilst maintaining security. We checked 14 emergency trolleys on wards, in theatres and the IRU and found them all to be secure and checked according to the trust policy with no omissions in the preceding three months. At our last inspection, we found emergency equipment trolleys in theatres for difficult intubations, children’s and outreach trolleys to be inconsistently checked and for some records not to be available. On this inspection we found that the equipment was secured, easily accessible and had been checked regularly according to trust policy. In theatres, staff were using a QR code to monitor the completion of resuscitation checks. QR codes are similar to bar codes and can uniquely identify items. Once the check had been completed, a member of staff scanned the code. This alerted managers that the check had been completed. If the check was not completed by 2pm, managers would escalate this and ensure the check was completed. Other equipment that was properly checked and tested included the blood fridge, ECG machines and diathermy equipment. However, we found warming cabinets in theatres did not have temperatures checked or recorded so staff could not be sure they were maintaining the correct temperature. At our last inspection in IRU, lead aprons were found to be out of date for testing to ensure they were safe for continued use. On this inspection we found that a large number of the aprons had been replaced and that there was a clear and effective process in place for tracking lead aprons and record kept of when they should receive their annual test. This amounted to over 600 lead aprons. All lead aprons were electronically tracked to ensure they were tested and replaced at the required intervals. All staff in IRU were observed wearing appropriate personal protective equipment including thyroid collars when required. At Cromer the environment was appropriate for the care and level of procedures being carried out there. There was sufficient room between trolleys to allow for recliner chairs and monitoring equipment. We checked four pieces of equipment and found them all to be serviced correctly. There was a register of equipment which was maintained and indicated when equipment had been serviced or was scheduled for servicing. The emergency resuscitation trolley was tamper proof. Records showed that it had been checked, according to trust policy, with no gaps in the last two months. The blood fridge maximum, minimum, average and current temperature were checked daily. Records showed it was checked daily with no gaps. The checklist and paper chart recorder were sent to the blood bank at the Norfolk and Norwich hospital for audit. Blood was held for short periods only for the purpose of planned transfusions. There was no blood or blood components stock kept in the fridge. Cleaning materials that were covered by control of substances hazardous to health COSHH were locked and secured in line with legislation. Lead aprons used in theatres were all risk assessed and were checked and tested monthly for integrity.

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Assessing and responding to patient risk In common with the rest of the trust, surgical areas used Early Warning Scores (EWS) to identify and escalate deteriorating patients. EWS is a national tool which scores a patient’s vital signs to assess their physiological stability and their risk of deterioration. Staff we spoke with understood the scoring system and what to do in the event of a raised score. This was escalation of the patient to a doctor or the critical care outreach team. Staff said they felt confident in escalating patients for review that they were concerned about and could refer patients for review based on clinical judgement and not just the patients EWS. Staff felt particularly well supported by the outreach team who would review patients, offer advice and escalate to consultants. However, in two records of fourteen reviewed we observed that whilst EWS had been correctly calculated, there was no evidence in the records of escalation as required by the procedure. In both cases the patients had been reviewed as part of a ward round the same day. At our last inspection we found the day procedure unit (DPU) was being used as an escalation area. We found the environment in part of the unit to be unsuitable and that the patients cared for were frequently complex. Staff at the time told us they did not have the skills to care for the complexity of patients on the unit. At this inspection we found that the DPU was being used for escalated patients from the 7th January 2019. There were 24 on the ward. There was now a standard operating procedure (SOP) in place to determine the appropriateness of patients to be cared for on DPU. We reviewed records and found that patients on DPU were suitable to be there, in line with the SOP. The area that was most unsuitable for inpatient care which consisted of six small cubicle areas, was no longer in use for inpatients and solely used for day case patients. Staff told us that they now received more appropriate, low acuity patients for DPU and that the staff on the unit were skilled to care for them. Inpatients and day case patients on the DPU were no longer mixed and staff were clear about the allocated patients they cared for without the competing demands of caring for inpatients as well as day procedure patients. Staff told us they had received training in sepsis, its identification and treatment. The sepsis six bundle was in use at the trust. This instructs staff in actions to take in the case of suspected sepsis with a low threshold in activating the bundle so that patients are not missed. We saw seven sepsis six bundles had been completed when patients were at risk and that the appropriate actions had been taken. Risk assessments were completed for patients on admission and at regular times during their stay. Risk assessments included falls risk, malnutrition risk and pressure area risk. Surgical pre- assessment used standard criteria to determine the relative risk of patients undergoing surgery. There was a clear process for identifying patients who may be at greater risk due to health complexities who would be escalated for review by an anaesthetist. The trust had undertaken further work on embedding the World Health Organisation (WHO) and five steps to safer surgery checklist in theatres and the IRU. We observed seven WHO checklists being undertaken and all were completed in full. Audit data showed that compliance for completion of the WHO checklist was 97% or greater in main theatres since September 2018. In obstetric theatre compliance was 98% or greater for the same time period and in ophthalmology theatres was 96% or greater although this had been on a small downward trend since November 2018. Managers were aware of the audit results and had identified the small downturn in audit performance. They were undertaking additional interventions to ensure WHO compliance.

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Theatres completed observational audits of the WHO checklist. At our last inspection these were completed by the same theatre team as were working in that operating theatre. At this inspection we found these quality audits were being completed by an independent member of staff. Audits showed an overall improvement in the engagement of theatre teams in the process. There was no formal handover of patients to the theatre escort from the wards. Whilst a theatre checklist was completed, the theatre escort did not request a verbal handover from ward staff before taking the patient to theatre. On one occasion we observed a patient collected for theatre without a handover from ward staff and the theatre preoperative checklist completed over four hours previously. We were concerned that a change in the patient’s condition may not be fully explained to theatre staff before the patient left the ward for theatres. We were told that there was no check on a patient being marked before being taken to theatres even though this had been an issue as part of a recent serious incident and never event. We were also concerned that this practice did not meet guidelines under National Safety Standards for Invasive Procedures (NatSSIPS) which states that all handovers should be both written and verbal. Out our last inspection we were concerned about the safety and privacy of patients requiring an anaesthetic for computed tomography (CT) or magnetic resonance imaging (MRI) scanning. Work had now started to allow patients to be safely anaesthetised and recovered in a CT room. There was sufficient equipment to ensure a patient’s safety. The design and layout had been completed with anaesthetists to ensure the safety of patients who required this level of care. There was a new SOP that clearly detailed ownership and individual responsibilities for the area. Since our last inspection, there was now a formal compliance audit of the WHO checklist in the IRU. Observational audits had been introduced by the matron for the area. Senior managers told us that staff recognised the importance of safety checks being completed. There was a plan to introduce a ‘mystery shopper’ to test the robustness of the quality audits in IRU and radiology more generally. The ophthalmology theatres had instigated a new of out of hours on call rota for emergencies which ensured staff with specialist skills were available when required. Main theatres had put in place safety champions in each theatre which staff told us had been a positive initiative which would improve safety though data to support his was not yet available. All surgery at Cromer is under local anaesthetic, with no provision on site for more complex procedures that require general anaesthesia or sedation. There is no provision on site for overnight admissions. Patients were appropriately monitored after their procedure and vital signs recorded. There were discharge criteria in use that ensured patients were fit to be discharged. In the event of an emergency, or if a patient deteriorated, they were transferred to the acute hospital for care which was supported by a transfer policy. This could be arranged through the ambulance service or, if urgent, a 999 call. Staff would be supported by staff from the minor injuries unit in the event of an unwell or deteriorating patient. Staff told us this could sometimes be a challenge if the Norfolk and Norwich was very busy though there were no incidents reported in relation to this. When we last inspected Cromer hospital in 2015 we raised concern that there were no local audits or measurement of the quality of the World Health Organisation (WHO) and five steps to safer surgery checklists. This had improved and we saw that checklists were completed and a process for audit had been introduced in theatres. We observed two WHO checklists being fully completed during procedures. WHO observational audits of the five steps were completed for a week every month. Data on site showed compliance of 98% or more for the months we reviewed. At our last 20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 144 inspection of Cromer, we had raised concerns there was a risk of complacency amongst the team as, when questioned, no formal assurance that checks were undertaken appropriately could be given apart from the team being small and all staff knew each other. Despite the introduction of the monthly observational audit we remained concerned that this risk remained. Whilst independent audit checks had been introduced at the Norfolk and Norwich hospital the observational audit at Cromer was completed by the same team working in theatres and there was limited check and challenge. For example, the patient details were read out by a member of the team to the patient for the patient to agree instead of asking the patient to tell the team their details in the first instance which is no longer best practice. We observed a pre- procedure theatre checklist being completed fully. Allergies, previous procedures and medical history were all checked. Histology specimens were double checked in theatre by the surgeon. Specimens from Cromer were collected three times daily and transported to the laboratory at the Norfolk and Norwich hospital. There was a clear specimen log in use to enable tracking of specimens. Each specimen and test required was logged on an electronic system.

Nurse staffing The service did not always have enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. Shifts did not always have the planned numbers of registered nurses. It was not clear that patient acuity was always considered in determining shift numbers. The trust has reported their staffing numbers at March 2018 and at September 2018 for qualified nursing staff in surgery. The number of actual staff (WTE) has remained stable between the two points in time, although the trust has increased their planned establishment by 16.8 WTE staff. As at September 2018, there was a fill rate of 87.2% for qualified nursing staff in surgery.

As at March 2018 As at September 2018 Actual Planned Actual Planned staff – staff – Fill staff – staff – Fill Site WTE WTE rate WTE WTE rate Norfolk and Norwich University Hospital 548.7 603.2 91.0% 538.7 619.7 86.9% Cromer Hospital 18.6 22.5 82.6% 21.7 22.8 95.5% Trust wide 567.4 625.7 90.7% 560.5 642.5 87.2% (Source: Routine Provider Information Request (RPIR) –Total staff tab)

Vacancy rates From September 2017 to August 2018, the trust reported a vacancy rate of 11.4% for qualified nursing staff in surgery. The trust does not have a target for vacancy rate. A breakdown by site can be found below. • Norfolk and Norwich University Hospital: 11.4% • Cromer Hospital: 12.1% (Source: Routine Provider Information Request (RPIR) – Vacancy tab)

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Turnover rates From October 2017 to September 2018, the trust reported a turnover rate of 8.5% for qualified nursing staff in surgery. This was lower than the trust target of 10.0%. A breakdown by site can be found below. • Norfolk and Norwich University Hospital: 8.1% • Cromer Hospital: 24.2% (Source: Routine Provider Information Request (RPIR) – Turnover tab)

Sickness rates From September 2017 to August 2018, the trust reported a sickness rate of 4.4% for qualified nursing staff in surgery. This was greater than the trust target of 3.5%. A breakdown by site can be found below. • Norfolk and Norwich University Hospital: 4.5% • Cromer Hospital: 3.9% (Source: Routine Provider Information Request (RPIR) – Sickness tab)

Bank and agency staff usage From September 2017 to August 2018, the trust reported that 101,482 of the 1,449,711 establishment hours were filled by bank staff (7.0%) and 37,893 hours were filled by agency staff 2.6%). There were 192,021 hours that needed to be covered by bank or agency that were unfilled (13.2%). A breakdown of bank and agency usage by staff type is shown below: Total establishment Staff type Bank hours Agency hours Unfilled hours hours Qualified 25,236 (2.3%) 20,665 (1.9%) 144,004 (13.3%) 1,078,708 Non-qualified 76,247 (20.6%) 17,228 (4.6%) 48,017 (12.9%) 371,002 Total 101,482 (7.0%) 37,893 (2.6%) 192,021 (13.2%) 1,449,711 (Source: Routine Provider Information Request (RPIR) - Nursing bank agency tab) The trust continued to have significant nurse vacancies with an 11% vacancy rate in surgery. There had been an uplift in staff numbers in some clinical areas based on the acuity of patients being cared for or the increase in activity in those areas. The trust had recruited a number of nurses for theatres and ward areas which ward managers told us had made a positive difference in how they managed their wards. Staffing on the wards and in clinical areas was assessed three times daily. This allowed senior staff to monitor acuity, demand and resource and redeploy staff to meet clinical need. Staff told us that this was sometimes difficult if a number of areas had reduced staffing at the same time. The number of staff on surgical wards was variable and in some areas tailored to the acuity of the patients in that area. However, the number of registered nurses for day shifts were set at five on a number of wards including trauma and orthopaedics, lower GI and general surgery and upper GI surgery although the acuity and support the patients required was different. Patient acuity and staffing levels was reported three times a day to the operations centre where clinical and non- clinical managers could make decisions about staffing and, if necessary redeploy staff to areas that required them.

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On three wards we found the shifts to be short of one registered nurse for the morning and afternoon shift. This meant the wards were not meeting their minimum staffing levels. Staff we spoke with told us this was not uncommon. We reviewed rotas on two wards and found that in the preceding month, there had been between 15 to 20 shifts that were not filled with the correct number of registered nurses. Most shifts for health care assistants were filled. Shift fill rate data showed that there had been general improvement in the number of registered nurses actually on shift compared to those planned to be on shift. However, some wards had been significantly below the planned shift fill rate. Docking ward average fill rate for registered nurses was 78% in July 79% in August 78% in September rising to 93% in November 2018. Denton ward was at 89% in July, 80% in August, 78% in September and falling to 67% in October 2018. This improved to 84% in December 2018. All wards, with the exception of Easton ward were consistently below the required registered nurses for day shifts between July and December 2018. For night shift fill rates for registered nurses, Easton was at 83% in July but improved for the following months. Denton ward also had less nurses than planned at night in August, September and October when an average of around 82% of registered nurse night shifts were filled. More wards had the required number of registered nurses at night than day shifts, on average the majority were under the planned number of staff. In some instances, there was an overfill of healthcare assistants but this was not always the case. Easton ward was a combined emergency assessment unit for attending patients and inpatient ward. During our inspection there were inpatients in the assessment unit. Staff on the ward and assessment unit were busy and three staff told us it was a very busy area at times. Easton ward was not routinely staffed at night to cover the assessment area which should be empty if being used for its intended purpose. Instead, staff caring for patients in the inpatient ward covered the additional beds. A number of staff told us that staff felt stretched on the ward if they had additional inpatients overnight. Vacancies were variable across wards with some areas such as Gateley ward only having one vacancy for a registered nurse, Denton ward that had 8.8 whole time equivalent vacancies for registered nurses and Easton had four registered nurses. Staff on Denton ward told us that they frequently used agency staff to support permanent staff. At the time of inspection there were no vacancies for nursing staff at Cromer. Rota’s showed there was adequate staffing for the ward and theatres, typically three members of staff in each area which was sufficient for the acuity of patients cared for. Gaps in the rota were not common. There was no agency use at the unit. A number of staff had left the service for other career opportunities or retirement. The small number in the team meant that this showed as a comparatively high turnover rate.

Medical staffing The trust has reported their staffing numbers at March 2018 and at September 2018 for medical and dental staff in surgery. The number of actual staff (WTE) had increased between the two points in time, with the fill rate for medical and dental staff increasing from 91.5% in March 2018 to 94.9% in September 2018.

As at March 2018 As at September 2018 Actual Planned Actual Planned staff – staff – Fill staff – staff – Fill Site WTE WTE rate WTE WTE rate

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Trust wide 337.3 368.6 91.5% 350.1 368.9 94.9% Note: The trust was unable to provide staffing data at site level for medical and dental staff in surgery. (Source: Routine Provider Information Request (RPIR) –Total staffing tab)

Vacancy rates From September 2017 to August 2018, the trust reported a vacancy rate of 7.7% for medical and dental staff in surgery. The trust does not have a target for vacancy rate. Note: The trust was unable to provide vacancy data at site level for medical and dental staff in surgery. (Source: Routine Provider Information Request (RPIR) – Vacancy tab)

Turnover rates From October 2017 to September 2018, the trust reported a turnover rate of 5.6% for medical and dental staff in surgery. This was lower than the trust target of 10.0%. Note: The trust was unable to provide turnover data at site level for medical and dental staff in surgery. (Source: Routine Provider Information Request (RPIR) – Turnover tab)

Sickness rates From September 2017 to August 2018, the trust reported a sickness rate of 0.9% for medical and dental staff in surgery. This was lower than the trust target of 3.5%. Note: The trust was unable to provide sickness data at site level for medical and dental staff in surgery. (Source: Routine Provider Information Request (RPIR) – Sickness tab)

Bank and locum staff usage From September 2017 to August 2018, the trust reported that 22,631of the 755,427 establishment hours were filled by bank staff (3.0%) and 2,240 hours were filled by medical locum staff (0.3%). There were 19,454 hours (2.6%) that needed to be covered by bank or medical locum staff but were unfilled. A breakdown of bank and medical locum usage by unit/ward is shown below: Total establishment Unit/ward Bank hours Locum hours Unfilled hours hours Anaesthetics 1,356 (0.7%) 0 0 201,856 ENT 1,387 (3.3%) 412 (1.0%) 0 41,756 General surgery 3,127 (2.7%) 144 (0.1%) 1,120 (1.0%) 113,880 Ophthalmology 2,173 (3.6%) 0 2,461 (4.1%) 60,757 General surgery 4,378 (12.6%) 680 (2.0%) 0 34,790

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Orthopaedic & Trauma 2,194 (1.8%) 0 1,669 (1.4%) 118,886 Plastic surgery 5,467 (9.3%) 349 (0.6%) 125 (0.2%) 58,880 Thoracic surgery 1,468 (7.4%) 560 (2.8%) 939 (4.8%) 19,710 Urology 785 (1.3%) 96 (0.2%) 10,429 (16.7%) 62,572 Vascular surgery 298 (0.7%) 0 2,711 (6.4%) 42,340 Total 22,631 (3.0%) 2,240 (0.3%) 19,454 (2.6%) 755,427 (Source: Routine Provider Information Request (RPIR) - Medical agency locum tab)

Staffing skill mix As at July 2018, the proportion of consultant staff reported to be working at the trust was higher than the England average and the proportion of junior (foundation year 1-2) staff was lower.

Staffing skill mix for the whole time equivalent staff working at Norfolk and Norwich University Hospitals NHS Foundation Trust This England Trust average Consultant 55% 48% Middle career^ 8% 11% Registrar Group~ 27% 27% Junior* 9% 13%

^ Middle Career = At least 3 years at SHO or a higher grade within their chosen specialty ~ Registrar Group = Specialist Registrar (StR) 1-6 * Junior = Foundation Year 1-2 (Source: NHS Digital Workforce Statistics)

There were adequate numbers of surgical doctors in most specialties to provide cover for theatres and surgical wards. However, there were vacancies in urology with 16% of urology consultant hours being unfilled. All surgical specialties had on call arrangements for out of hours cover as well as having an on-site presence for ward rounds in the mornings at weekends. Orthopaedics provided onsite cover for trauma patients seven days a week. There were some specialties such as urology where recruitment was ongoing to fill these vacancies. Senior staff had a clear plan to manage the services which included working with other NHS trusts to manage patient pathways aligned to the resource available. Handovers took place at varying times, partially dependent on theatre operating lists. Medical staff working at Cromer were employed at the Norfolk and Norwich Hospital and undertook part of their work at Cromer Hospital.

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Records Staff did not keep appropriate records of patients’ care and treatment. Records were not always clear, and there were gaps and omissions in patient records. Records were not always stored securely. Records were predominately paper based and kept in trolleys by bays on each ward. All the trolleys we saw were unlocked and on numerous occasions we saw lids up so that notes could be seen and were easily accessible to any one visiting the ward. On two occasions we saw patients notes left on a table away from the notes trolley and next to a public area where they remained for some time until we brought them to the attention of staff. On one set of records was affixed a box of medicines which were not secured. We reviewed 14 sets of notes from five different clinical areas. Notes included medical records, nursing and AHP records and nursing risk assessments including venous thromboembolism (VTE) assessment, falls, pressure area assessment and the malnutrition universal assessment tool (MUST). Not all records were fully completed. In eight sets of records there were omissions in the intentional rounding documentation. In 12 records there were gaps in fluid charts, including lack of input or output measures or that they were not totalled. In six records the cannula check sheet was not completed for every shift as was required. In four records we found that Waterlow pressure ulcer risk scores were not recalculated every three days as was required. This meant we were not assured that patient monitoring and risk assessment was effective as records were not consistent with policy. In some records, staff of different specialities such as therapies or specialist nurses affixed a coloured sticker to their entry in the records. This allowed staff to quickly see who had reviewed a patient and when. However, we found the use of these to be very inconsistent with around half of the records we reviewed having none of the stickers at all. There remained delays in discharge summaries being sent to GP’s with the longest delays being in trauma and orthopaedics. This meant that patients requiring care form their GP could not be assured their GP would have the most up to date information about their care. At Cromer we found records were now consistent with those used at the Norfolk and Norwich Hospital. At our previous inspection in 2015 we had found this not to be the case. We reviewed three sets of records. All records such as theatre checklist, procedure notes and theatres summary and nursing records were fully completed. The sterile set used for the procedure was recorded in the records to allow tracking. Records were stored securely. Following a previous incident, staff confirmed that no procedure would go ahead without full patient records being available. The established specimen process at Cromer required specific printed labels to be produced and added to specimen request forms and specimen bottles. The surgeon completed the request electronically in theatre. To avoid multiple changes between paper and labels, the senior leadership team at Cromer had organised that the printer on the ward would be used for intraoperative documents and loaded with paper. The printer was removed from theatres and reallocated into an administration office for the purpose of printing labels. This meant that the correct printer needed to be selected for each individual print job and a member of theatre staff had to leave the theatre to either go to the ward, to retrieve the perioperative documents that were required to be added to the patients notes after the case or to the administration office to collect

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 150 the printed labels. The administration area was some distance from theatre and required walking through public areas to access. We found this caused disruption to the theatre list and also posed a potential information governance risk to patient confidentiality should the wrong printer be selected and patient notes sent to various areas of the hospital. Staff were unaware why the printer had been removed from theatre. We raised it on site with the hospital matron who stated this would be addressed.

Medicines The service prescribed and gave medicines well. Patients received the right medication, at the right dose, at the right time. There were inconsistent medication checks on Edgefield ward. Medicines were prescribed electronically at the trust. The system was able to flag essential information such as allergies or if a medicine was overdue or not due on that day. It created a clear audit trail for managers as well as allowing pharmacy staff to track medicines usage across different wards so that they could ensure appropriate medicines were in the right areas at the right time. Medicines were properly prescribed and administered to patients in a timely way. We saw electronic prescription charts that showed medicines were given according to prescription when the patient required them. We observed staff administering medicines. We saw staff checking the prescription, patients detail and confirmed this against the patient’s wristband. They stayed with the patient whilst they took their medicine and aided them if it was required. Medicines reconciliation was completed by the pharmacy teams for the wards and completed on a daily basis or if there were any discrepancies. In busy areas, such as Easton ward, dedicated pharmacists were attached to the ward to support staff and patient safety. We checked a sample of medicines and intravenous fluids on four surgical wards and found them all to be in date and stored securely. We checked fridges in seven different clinical areas. We found them to all be within temperature range. The maximum, minimum and current temperature was recorded. In records we looked at there were no gaps in the preceding three months with the exception of Edgefield ward where there were gaps in each month between September and December 2018. Ambient room temperatures were also now recorded with the temperatures recorded. All were within acceptable ranges. An audit on Edgefield ward showed consistently poor results for keeping cupboards locked, medicines being locked away and drug trolleys being tethered when not in use. However, on two wards we found the fridges to be unlocked. On one of the fridges was affixed a large sign stating the fridge should be locked. Controlled drugs (CD’s) were kept in secure cupboards in clean utility rooms in the ward areas. We reviewed CD registers and found all medicines to be signed out by two people. There was evidence of weekly stock reconciliation. There were no gaps in the registers we reviewed. In theatres, most fridges were checked regularly and temperatures recorded. However, in theatre 14 there were gaps in the checking record for July, August and September 2018 but no indication if the theatre was not in use on those days.

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At or last inspection we found concerns with medicines and contrast in interventional radiology. At this inspection we found that monthly audits for medicines in IRU showed 100% compliance. Medicines were stored securely and pharmacists did regular walk rounds to ensure correct use of and storage of medicines. In IRU, medicines keys were secured in key safes and storage temperature were now monitored and a drugs audit held monthly. This showed full compliance with trust standards. There were a small number of medicines at Cromer. We saw that medicines were stored securely and at the correct temperature. Keys for medicines were kept in a secure box which could only be accessed with a number code. Fridge’s containing medicines were kept locked. Temperatures were complete daily and included minimum, maximum and current temperature. Records showed these had been consistently recorded with no gaps. Al temperatures were within in the expected range. Medicines in theatres were secured, a sample was checked and found to be in date. There were no controlled drugs used at Cromer. A pharmacist or pharmacy technician visited the hospital weekly for stock top ups and reconciliation. There were two patient group directions (PGD) in place at Cromer. PGDs provide a legal framework which allows some registered health professionals to supply and/or administer specified medicines, such as painkillers, to a predefined group of patients without them having to see a doctor. The PGDs had been developed with pharmacy with clinical input and had been read and signed by the relevant staff.

Incidents Never Events The service did not manage patient safety incidents well. There were a further two never events in surgery since our last inspection. Work had been done to reduce never events but this was not fully embedded. Not all managers undertaking root cause analysis (RCA) had training to complete them. Local guidelines for theatres had not been developed in response to national guidelines. Never events are serious incidents that are entirely preventable as guidance, or safety recommendations providing strong systemic protective barriers, are available at a national level, and should have been implemented by all healthcare providers. Each never event type has the potential to cause serious patient harm or death but neither need have happened for an incident to be a never event. From November 2017 to October 2018, the trust reported one incident classified as a never event for surgery. The never event was reported for a surgical/invasive procedure incident meeting SI criteria within the ophthalmic theatres. Since we asked for the pre- inspection information the trust had a further never event making two in the period November 2017 to October 2018. The second incident was a wrong site injection. Both the never events had been thoroughly investigated with actions identified to prevent recurrence. Senior staff told us how disappointed they were with the second never event as there had been improvement in their processes and performance since 2017. We remained concerned

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 152 that, whilst there had been a reduction in never events, the division had not fully addressed the underlying causes as never events continued to happen. Theatre staff could tell us about the never events and learning from them. Divisional leadership told us they had reviewed the never events from 2017 onwards to ensure that all actions identified had been completed. However, the implementation of some learning was slow. For example, there was ongoing work on the pre-operative checklist partly in response to an incident where a patients operative site had not been marked. At the time of our inspection this work was still ongoing over two months after the incident. We were told that whilst NatSSIPs were in place, and we saw evidence of this, there were no local safety standards for invasive procedures (LocSSIP’s) in place at the time of our inspection and that this work was in process. NatSSIPs had been published in September 2015 with guidance from CQC encouraging organisations review practice and develop local standards. The trust had identified human factors as a recurring issue in the never events. Prior to our inspection the trust had trained 140 staff in human factors and also had a number of staff trained as trainers for human factors training. This had been received positively in the surgical division. Staff we spoke with in theatres and ward areas were aware of the never events. Surgical staff could describe the lessons learnt from the never events and a number had received the human factors training. There had been no never events in the IRU since our last inspection. A newsletter circulated around the division entitled ‘Sharing the learning’ gave details and information of incidents and good practice. (Source: Strategic Executive Information System (STEIS))

Breakdown of serious incidents reported to STEIS In accordance with the Serious Incident Framework 2015, the trust reported 35 serious incidents (SIs) in surgery which met the reporting criteria set by NHS England from November 2017 to October 2018. The breakdown by incident type was as follows: • Pressure ulcer meeting SI criteria with 12 (34% of total incidents). • Treatment delay meeting SI criteria with 10 (29% of total incidents). • Slips/trips/falls meeting SI criteria with four (11% of total incidents). • Surgical/invasive procedure incident meeting SI criteria with two (6% of total incidents). • Environmental incident meeting SI criteria with two (6% of total incidents). • Apparent/actual/suspected self-inflicted harm meeting SI criteria with one (3% of total incidents). • Medication incident meeting SI criteria with one (3% of total incidents). • Abuse/alleged abuse of adult patient by staff with one (3% of total incidents). • Abuse/alleged abuse of child patient by third party with one (3% of total incidents). • Adverse media coverage or public concern about the organisation or the wider NHS with one (3% of total incidents). (Source: Strategic Executive Information System (STEIS))

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Incidents were reported by an electronic system that all staff we spoke with were able to access. Staff told us what constituted an incident (including a near miss) and how and when they should report them. Feedback from incidents was given to staff either individually or through meetings or other communications such as emails. Four members of staff told us that they had received feedback about incidents they had reported although three other members of staff could not recall receiving feedback about an incident they had raised. All the staff we spoke with told us that they were confident and felt support to raise incidents. Ward managers were able to tell us about the incidents in their areas, the themes and what they were doing to reduce risk of recurrence. There was a daily (Monday to Friday) serious incident group (SIG) which reviewed incidents from the day before. It was attended by representatives from areas that had reported incidents as well as senior clinical staff. It was chaired by the chief nurse. SIG allowed for rapid senior review of incidents, prompt mitigation and cross division and trust wide learning. All the staff we spoke with told us it was a positive experience and encouraged transparency with no blame attached. Learning from incidents was shared with staff in the division and, if required, across the trust. Most of the staff we spoke with told us that their ward managers kept them informed about incidents and learning either through meetings, a newsletter, at safety huddles or email. We saw meeting minutes that showed incidents were a standing agenda item and were discussed at the bimonthly meetings. Safety huddles were held daily on the wards to give staff updates and feedback as well as setting priorities for the shift. Incidents were investigated by a variety of different senior staff depending on the nature of the incident. Whilst all staff who had investigated incidents had received training in patient safety, not all investigators who were required to undertake root cause analysis had received training to do so. In theatres positive action had been taken following a number of incidents in 2017/ 18 in relation to implants. Staff told us that practice had changed for the better following a new implant policy. In ophthalmology theatre, staff were aware of previous incidents and could demonstrate changes in practice, for example there were additional lens implant checks before any implant was used. We observed these checks being carried out during a procedure. In IRU, incidents were fully investigated though some incidents were not fully investigated at 24 days. We were told this was mainly due to staffing issues. However, the number of outstanding incidents was small representing an improvement on our last inspection. The duty of candour creates a legal duty upon healthcare professionals to be honest and open with patients when something goes wrong with their treatment or care, or has the potential to cause harm or distress. Senior staff were able to tell us about the process for implementing the duty of candour following an incident or complaint that was covered by the duty. Two senior staff we spoke with had been involved with a meeting following an incident, explaining the cause of the incident and offering an apology. Junior staff were able to tell us what the duty of candour was and their personal and professional responsibilities under the duty. One member of junior staff had attended a meeting with a patient and relative and told us they found them beneficial; in allowing clear communication and an open conversation. There was a mortality surveillance group that considered aspects of mortality and contributing factors across the divisions. Minutes were detailed and showed actions and overview of death reviews internally and externally. Mortality meetings considered flagged deaths within the trust for discussion as well as benchmarking against national audit and outcomes.

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At Cromer, the governance of incidents was integrated with the Norfolk and Norwich University hospital. The matron attended SIG if necessary. Staff were able to report incidents and could describe the way they would do this. Staff provided an example of an incident, in one case regarding care of a patient who required emergency care for their mental health, and the associated learning, in that instance developing a flow chart to ensure consistency of process. There were debriefs and learning shared by the matron for the hospital for staff. Staff were aware of the duty of candour in relation to their work.

Safety thermometer The service used safety monitoring results well. Staff collected safety information and shared it with staff, patients and visitors such as safety thermometer data that was displayed prominently in public areas. The Safety Thermometer is used to record the prevalence of patient harms and to provide immediate information and analysis for frontline teams to monitor their performance in delivering harm free care. Measurement at the frontline is intended to focus attention on patient harms and their elimination. Data collection takes place one day each month – a suggested date for data collection is given but wards can change this. Data must be submitted within 10 days of suggested data collection date. Data from the Patient Safety Thermometer showed that the trust reported 36 new pressure ulcers, seven falls with harm and four new catheter urinary tract infections from October 2017 to October 2018 for surgery.

Prevalence rate (number of patients per 100 surveyed) of pressure ulcers, falls and catheter urinary tract infections at Norfolk and Norwich University Hospitals NHS Foundation Trust

1 Total Pressure ulcers (36)

2 Total Falls (7)

3 Total CUTIs (4)

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1 Pressure ulcers levels 2, 3 and 4 2 Falls with harm levels 3 to 6 3 Catheter acquired urinary tract infection level 3 only (Source: NHS Digital) The trust used a performance dashboard for each clinical area to monitor the prevalence of pressure ulcers, falls, catheter acquired urinary tract infections amongst other things. Some of this data was displayed so that the public could see it on entry to the ward whilst more detailed high impact audit data was available for staff on the ward. Information included the last case of C. Diff on the ward, last grade two pressure ulcer and falls with harm amongst others. Information was updated monthly and formed part of a more detailed dashboard. Since our last inspection theatres had developed a safety dashboard that was now in use. This contained comprehensive performance and quality data that fed into governance meetings. It was also available for staff to review and contained all necessary information for management. Cromer Hospital displayed a safety dashboard detailing incidents, complaints and concerns. Staff could tell us about trends over time and what the themes of incidents and complaints were.

Is the service effective? Evidence-based care and treatment The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance. There were processes in place to ensure that national guidance supported local trust policies. New National Institute for Clinical Excellence (NICE) guidance was reviewed by relevant clinical staff to determine any actions required to ensure the trust was working to the guidance. This process was owned centrally with a clear tracker of which guidance was reviewed. We reviewed a selection of policies on site and after the on-site inspection and found them to be up to date, version controlled and within review date. Staff knew how to access policies and were able to do so promptly when required. There was a full clinical audit plan in place in the division. A nominated clinical lead was identified for each audit along with a timeframe for the audit and its completion. The audit plan encompassed national audit requirements as well as routine re-audit of certain clinical topics, those identified from clinical interest or particular incidents that highlighted an area for improvement. We were concerned about the lack of some practice audit in theatres. For example, there had been an incident relating to the lack of marking of a patient but theatres had not audited marking. Action plans had been developed following audits including the large scale national audits such as the national hip fracture audit and national laparotomy audit. Actions were clear and achievable with nominated individuals responsible as well as local audit to follow up implementation. We reviewed care pathways in a number of specialities including trauma and orthopaedics, general surgery and urology. Pathways followed national guidance from pre- admission (NICE guidance NG45), pre, intra and post operatively (NICE guidance CG92) and at discharge (NICE guidance CG124).

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Patients care was risk assessed and their care planned based on national and local guidance. This included assessment using nationally recognised tools for falls, pressure ulcer risk, venous thrombosis and anaesthetic risk amongst others. There were a number of enhanced recovery pathways for different specialities or procedures including lower GI surgery and colorectal surgery. This included early mobilisation, eating and drinking aiming at ensuring patients were fit for discharge earlier. At Cromer, pathways for minor procedures followed national guidance and best practice. There was a range of audit activity at Cromer hospital including hand hygiene, uniform, cannula and catheter audits.

Nutrition and hydration Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary. The service made adjustments for patients’ religious, cultural and other preferences. Patients were supported with their nutrition and hydration needs throughout their stay. Nutritional assessments were completed using the malnutrition universal screening tool (MUST) which identified those at risk and what actions to take. This included referral to dieticians and other allied health professionals. Some patients required specific diets following surgery such as low sodium, clear fluid and soft diets. These patients were fully catered for to support their recovery. Other forms of nutritional support were also given such as total parenteral nutrition (TPN) and enteral feeding if this was indicated following surgery. Staff we spoke with in the areas that would most commonly care for these methods of nutrition were confident in managing them. Patients were regularly prescribed anti emetic medication to control nausea and vomiting. Records showed that this was discussed with patients at pre-operative assessment and a plan made to manage any nausea post operatively. Dieticians and speech and language therapists were available for patients who required assessment or specialist support. Records showed that patients who required their support were referred appropriately and seen promptly. We observed patients being assisted with meals and hydration throughout the inspection. Patients were frequently offered drinks and had drinks within reach. At Cromer patients could eat and drink as normal ahead of their procedure. This was explained at pre- admission clinic. Drinks were available on the ward immediately post operatively and we saw staff could get food for patients should they require it. Most patients were discharged shortly after their minor procedure. There were facilities for purchasing food and drink within the hospital.

Pain relief Elective patients had a pre-operative plan made for their pain relief intra and post operatively. This allowed patients to discuss the options and make an informed choice about pain relief.

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Pain levels were scored post operatively during the ward intentional rounding. Records showed that in three records we reviewed patients were given appropriate pain relief after giving a higher score for pain on the intentional rounding. Different pain relief methods were available including patient controlled analgesia, epidural and pain relief via injection. We spoke with 11 patients who told us that their pain was well controlled during their recovery. They told us that pain relief was given promptly if they needed it. There was support from the acute pain team if patients required additional support or who had complex needs. In one complex case, we saw that the chronic pain team had been involved and had worked with the acute pain team to form a plan for the patients care. Local anaesthetic was used for patients at Cromer. Staff checked pain levels with patients post operatively and they were encouraged to take over the counter analgesia if they required pain relief at home following their surgery.

Patient outcomes Relative risk of readmission Trust level From July 2017 to June 2018; All patients at the trust had a higher expected risk of readmission for elective admissions when compared to the England average. • Urology patients at the trust had a higher expected risk of readmission for elective admissions when compared to the England average. • General surgery patients at the trust had a higher expected risk of readmission for elective admissions when compared to the England average. • Plastic surgery patients at the trust had a higher expected risk of readmission for elective admissions when compared to the England average.

Elective Admissions – Trust Level

Note: Ratio of observed to expected emergency readmissions multiplied by 100. A value below 100 is interpreted as a positive finding, as this means there were fewer observed readmissions than expected. A value above 100 represents the opposite. Top three specialties for specific trust based on count of activity

All patients at the trust had a lower expected risk of readmission for non-elective admissions when compared to the England average. • General surgery patients at the trust had a similar expected risk of readmission for non- elective admissions when compared to the England average.

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• Urology patients at the trust had a lower expected risk of readmission for non-elective admissions when compared to the England average. • Trauma and orthopaedics patients at the trust had a lower expected risk of readmission for non-elective admissions when compared to the England average.

Non-Elective Admissions – Trust Level

Note: Ratio of observed to expected emergency readmissions multiplied by 100. A value below 100 is interpreted as a positive finding, as this means there were fewer observed readmissions than expected. A value above 100 represents the opposite. Top three specialties for specific trust based on count of activity (Source: Hospital Episode Statistics - HES - Readmissions (01/07/2017 - 30/06/2018))

Norfolk and Norwich University Hospital From July 2017 to June 2018; All patients at Norfolk and Norwich University Hospital had a higher expected risk of readmission for elective admissions when compared to the England average. • Urology patients at Norfolk and Norwich University Hospital had a higher expected risk of readmission for elective admissions when compared to the England average. • General surgery patients at Norfolk and Norwich University Hospital had a higher expected risk of readmission for elective admissions when compared to the England average. • Plastic surgery patients at Norfolk and Norwich University Hospital had a higher expected risk of readmission for elective admissions when compared to the England average.

Elective Admissions - Norfolk and Norwich University Hospital

Note: Ratio of observed to expected emergency readmissions multiplied by 100. A value below 100 is interpreted as a positive finding, as this means there were fewer observed readmissions than expected. A value above 100 represents the opposite. Top three specialties for specific site based on count of activity

All patients at Norfolk and Norwich University Hospital had a lower expected risk of readmission for non-elective admissions when compared to the England average. • General surgery patients at Norfolk and Norwich University Hospital had a similar expected risk of readmission for non-elective admissions when compared to the England average.

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• Urology patients at Norfolk and Norwich University Hospital had a lower expected risk of readmission for non-elective admissions when compared to the England average. • Trauma and orthopaedics patients at Norfolk and Norwich University Hospital had a lower expected risk of readmission for non-elective admissions when compared to the England average.

Non-Elective Admissions - Norfolk and Norwich University Hospital

Note: Ratio of observed to expected emergency readmissions multiplied by 100. A value below 100 is interpreted as a positive finding, as this means there were fewer observed readmissions than expected. A value above 100 represents the opposite. Top three specialties for specific site based on count of activity

Cromer Hospital From July 2017 to June 2018; All patients at Cromer Hospital had a lower expected risk of readmission for elective admissions when compared to the England average. • Ophthalmology patients at Cromer Hospital had a lower expected risk of readmission for elective admissions when compared to the England average. • Urology patients at Cromer Hospital had a higher expected risk of readmission for elective admissions when compared to the England average. • Plastic surgery patients at Cromer Hospital had a higher expected risk of readmission for elective admissions when compared to the England average.

Elective Admissions - Cromer Hospital

Note: Ratio of observed to expected emergency readmissions multiplied by 100. A value below 100 is interpreted as a positive finding, as this means there were fewer observed readmissions than expected. A value above 100 represents the opposite. Top three specialties for specific site based on count of activity

Cromer hospital only has elective surgical activity so there are no non-elective admissions. (Source: Hospital Episode Statistics)

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The service monitored the effectiveness of care and treatment and used the findings to improve them. Performance in some national audits was positive including bowel cancer audit and National Ophthalmology Database Audit were in line with or better when compared to other hospitals. In most areas they compared local results with those of other services to learn from them. The National emergency laparotomy audit and national Oesophago-gastric Audit showed a mixed picture when compared to other hospitals. We requested action plans in relation to a number of the national audits but did not receive all of them. We were not assured that all steps were being taken to address poor performance in some national audit.

National Hip Fracture Database Norfolk and Norwich University Hospital The table below summarises Norfolk and Norwich University Hospital’s performance in the 2017 National Hip Fracture Database. For five measures, the audit reports performance in quartiles. In this context, ‘similar’ means that the trust’s performance fell within the middle 50% of results nationally. Meets national Hospital Comparison to Metrics (Audit indicators) aspirational performance other Trusts standard? Case ascertainment (Proportion of eligible cases included in 93.0% Similar  the audit) Crude proportion of patients having surgery on the day or day after admission (It is important to avoid any unnecessary delays for people who are 69.4% Similar  assessed as fit for surgery as delays in surgery are associated with negative outcomes for mortality and return to mobility) Crude peri-operative medical assessment rate (NICE guidance specifically recommends the involvement and 95.2% Similar  assessment by a Care of the Elderly doctor around the time of the operation to ensure the best outcome) Crude proportion of patients documented as not developing a pressure ulcer

4. (Careful assessment, documentation and preventative measures should be 98.5% Similar  taken to reduce the risk of hospital- acquired pressure damage (grade 2 or above) during a patient’s admission); this measures an organisation’s ability to report ‘documented as no pressure ulcer’ for a patient

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Crude overall hospital length of stay (A longer overall length of stay may indicate that patients are not discharged or transferred sufficiently 16.6 days Better No current standard quickly; a too short length of stay may be indicative of a premature discharge and a risk of readmission) Risk-adjusted 30-day mortality rate (Adjusted scores take into account the Worse than 9.0% No current standard differences in the case-mix of patients expected treated) (Source: National Hip Fracture Database) There was a full action plan in place following this audit with clinicians named to take actions forward. There was a focus on improving documentation which would accurately reflect patient care and pathway at the next audit. There had been reviews of the pathway for these patients and re audit was planned to review the effectiveness.

Bowel Cancer Audit The table below summarises the trust’s performance in the 2017 National Bowel Cancer Audit. Metrics Trust Comparison to other Meets (Audit measures) performance Trusts national standard? Case ascertainment Good is over (Proportion of eligible cases included 109.3% Good 80% in the audit) Risk-adjusted post-operative length of stay >5 days after Worse than national No current major resection 72.5% aggregate standard (A prolonged length of stay can pose risks to patients) Risk-adjusted 90-day post- operative mortality rate (Proportion of patients who died within 90 days of surgery; post-operative No current 2.0% Within expected range mortality for bowel cancer surgery standard varies according to whether surgery occurs as an emergency or as an elective procedure) Risk-adjusted 2-year post-operative mortality rate (Variation in two-year mortality may No current reflect, at least in part, differences in 15.2% Within expected range standard surgical care, patient characteristics and provision of chemotherapy and radiotherapy) Risk-adjusted 30-day unplanned readmission rate No current (A potential risk for early/inappropriate 10.4% Within expected range standard discharge is the need for unplanned readmission)

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Risk-adjusted 18-month temporary stoma rate in rectal cancer patients undergoing major resection (After the diseased section of the bowel/rectum has been removed, the No current 35.9% Positive outlier bowel/rectum may be reconnected. In standard some cases it will not and a temporary stoma would be created. For some procedures this can be reversed at a later date) Note regarding case ascertainment: Calculated using number of patients reported to the audit as a percentage of the number of patients admitted for the first time to the trust/network with a diagnosis of bowel cancer within the audit period according to HES. This can be larger than 100% if more patients are reported to the audit than identified in HES. (Source: National Bowel Cancer Audit)

National Vascular Registry The table below summarises the trust’s performance in the 2017 National Vascular Registry. Comparison Meets national Metrics Trust to other aspirational (Audit measures) performance Trusts standard? Abdominal Aortic Aneurysm Surgery (Surgical procedure performed on an enlarged major blood vessel in the abdomen) Case ascertainment (Proportion of eligible cases 89% Not applicable  included in the audit) Risk-adjusted post-operative in- hospital mortality rate Within the No current (Proportion of patients who die in 0.6% expected standard hospital after having had an range operation) Carotid endarterectomy (Surgical procedure performed to reduce the risk of stroke; by correcting a narrowing in the main artery in the neck that supplies blood to the brain) Case ascertainment Equal to audit (Proportion of eligible cases 90% Not applicable aspirational included in the audit) target Crude median time from symptom to surgery (Average amount of time patients 8 days Not applicable ✓ wait to have surgery after the onset of their symptoms) Risk adjusted 30-day mortality and stroke rate Within the No current (Proportion of patients who die or 2.1% expected standard have a stroke within 30 days of range their operation) (Source: National Vascular Registry)

National Oesophago-Gastric Cancer Audit The table below summarises the East of England Strategic Clinical Network performance in the 2016 National Oesophago-gastric Cancer Audit.

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Metrics Trust Comparison to Meets national (Audit measures) performance other Trusts standard? Trust-level metrics (Measures of hospital performance in the treatment of oesophago-gastric (food pipe and stomach) cancer) Case ascertainment No current (Proportion of eligible cases included 81% to 90% Better standard in the audit) Age and sex adjusted proportion of patients diagnosed after an emergency admission (Being diagnosed with cancer in an emergency department is not a good No current 23.9% Worse sign. It is used as a proxy for late standard stage cancer and therefore poor rates of survival. The audit recommends that overall rates over 15% could warrant investigation) Risk adjusted 90-day post- operative mortality rate Within expected No current 1.3% (Proportion of patients who die within range standard 90 days of their operation) Cancer Alliance level metrics (Measures of performance of the wider group of organisations involved in the delivery of care for patients with oesophago-gastric (food pipe and stomach) cancer; can be a marker of the effectiveness of care at network level; better co-operation between hospitals within a network would be expected to produce better results. Contextual measure only. Crude proportion of patients treated with curative intent in the Cancer Alliance No current 33.8% Worse (Proportion of patients receiving standard treatment intended to cure their cancer) (Source: National Oesophago-Gastric Cancer Audit) We requested the actions following this audit but did not receive the action for age and sex adjusted proportion of patients diagnosed after an emergency admission. There had been audit in relation to the diagnosis and management of Barrett’s oesophagus with actions identified following this.

National Emergency Laparotomy Audit Norfolk and Norwich University Hospital The table below summarises Norfolk and Norwich University Hospital’s performance in the 2017 National Emergency Laparotomy Audit. The audit reports on the extent to which key performance measures were met and grades performance as red (less than 50% of patients achieving the standard), amber (between 50% and 80% of patients achieving the standard) and green (more than 80% of patients achieved the standard. Metrics Hospital Meets national Audit’s Rating (Audit measures) performance standard? Case ascertainment (Proportion of eligible cases included 100% Green ✓ in the audit)

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Crude proportion of cases with pre- operative documentation of risk of death (Proportion of patients having their 100% Green ✓ risk of death assessed and recorded in their notes before undergoing an operation) Crude proportion of cases with access to theatres within clinically appropriate time frames 77% Amber (Proportion of patients who were  operated on within recommended times) Crude proportion of high-risk cases (greater than or equal to 5% predicted mortality) with consultant surgeon and anaesthetist present 43% in theatre Red  (Proportion of patients with a high risk of death (5% or more) who have a Consultant Surgeon and Anaesthetist present at the time of their operation) Crude proportion of highest-risk cases (greater than 10% predicted mortality) admitted to critical care post-operatively 65% Amber (Proportion of patients with a high risk  of death (10% or more) who are admitted to a Critical/Intensive Care ward after their operation) Risk-adjusted 30-day mortality rate (Proportion of patients who die within Within expected No current 30 days of admission, adjusted for the 9.4% range standard case-mix of patients seen by the provider) (Source: National Emergency Laparotomy Audit) We requested the action plan for the National Emergency Laparotomy Audit but did not receive it.

National Ophthalmology Database Audit The table below summarises the trust’s performance in the 2018 National Ophthalmology Database Audit. Metrics Trust Comparison to Meets national (Audit measures) performance other Trusts standard? Trust-level metrics (Measures of hospital performance in the treatment of cataracts

Case ascertainment No current (Proportion of eligible cases included 100.0% N/A standard in the audit)

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Risk-adjusted posterior capsule rupture rate (Posterior capsule rupture (PCR) is the index of complication of cataract Better than No current surgery. PCR is the only potentially 0.8% expected standard modifiable predictor of visual harm from surgery and is widely accepted by surgeons as a marker of surgical skill. Risk adjusted visual acuity loss (The most important outcome No data No current N/A following cataract surgery is the clarity available standard of vision) (Source: National Ophthalmology Database Audit)

National Joint Registry The table below summarises Norfolk and Norwich University Hospital’s performance in the 2017 National Joint Registry. Metrics Hospital Comparison to Meets national (Audit measures) performance other hospitals standard? Proportion of patients consented to have personal details included (hips,

knees, ankles and elbows)

(Patient details help ‘track and trace’ level - prosthetics that are implanted. It is 99.1% Better  regarded as best practice to gain

consent from a patient to facilitate Trust entering their patient details on to the register) Risk-adjusted 5 year revision ratio (for hips excluding tumours and Within expected neck of femur fracture) 1.00 range ✓ (Proportion of patients who need their hip replacement ‘re-doing’) Risk adjusted 90-day post-operative mortality ratio (for hips excluding Within expected tumours and neck of femur fracture) 1.00 range ✓ (Proportion of patients who die within Hospitallevel: Hips 90 days of their operation) Risk-adjusted 5 year revision ratio (for knees excluding tumours) Within expected 0.75 (Proportion of patients who need their range  knee replacement ‘re-doing’) Risk adjusted 90-day post-operative mortality ratio (for knees excluding Within expected tumours) 1.00 range ✓ (Proportion of patients who die within

90 days of their operation) Hospitallevel: Knees (Source: National Joint Registry)

National Prostate Cancer Audit

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The table below summarises the trust’s performance in the 2017 National Prostate Cancer Audit. Meets national Metrics Hospital Comparison to aspirational (Audit measures) performance other trusts standard? Men with complete information to determine disease status (This is a classification that describes how advanced the cancer is and 89.6% N/A includes the size of the tumour, the  involvement of lymph nodes and whether the cancer has spread to different part of the body) Percentage of patients who had an emergency readmission within 90 days of radical prostatectomy (A radical prostatectomy involves the surgical removal of the whole prostate Within expected No current 9.06% and the cancer cells within it; range standard emergency readmission may reflect that patients experienced a complication related to the surgery after discharge from hospital) Percentage of patients experiencing a severe urinary complication requiring intervention No current 5.2% Positive Outlier following radical prostatectomy standard (Complications following surgery may reflect the quality of surgical care) Percentage of patients experiencing a severe gastrointestinal complication requiring an intervention following No current 18.2% Positive Outlier external beam radiotherapy standard (External beam radiotherapy uses high-energy beams to destroy cancer cells) (Source: National Prostate Cancer Audit)

Patient Reported Outcome Measures In the Patient Reported Outcomes Measures (PROMS) survey, patients are asked whether they feel better or worse after receiving the following operations: • Groin hernias • Varicose veins • Hip replacements • Knee replacements Proportions of patients who reported an improvement after each procedure can be seen on the right of the graph, whereas proportions of patients reporting that they feel worse can be viewed on the left.

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In 2016/17 performance on groin hernias, hip replacement and knee replacements was about the same as the England average. For varicose veins, performance was worse than the England average for EQ VAS and better for Aberdeen varicose vein questionnaire. (Source: NHS Digital)

Competent staff The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service.

Appraisal rates The overall appraisal rate for the division was 87%. Docking ward had an appraisal rate of 84% and Denton 100%. The trust had a formal induction policy and process for new members of staff whether they were permanent or temporary. New nursing staff received a two week induction which comprised mandatory training and orientation to the hospital and ward. New staff were supernumerary for four weeks. Induction or supernumerary status could be extended for new starters if it was required to effectively support them into a new role. Some wards such as Edgefield had a number of new registered nurses. Staff told us they were concerned about skill mix in the short term although had put mitigation in place including buddy arrangements, supernumerary status and induction programmes. Staff told us they were supported with medical and nursing revalidation. This was in the form of formal processes within the trust as well as informal support processes on wards led by ward managers. Staff were able to access learning opportunities within the organisation and also external teaching and training opportunities. We spoke with a number of staff who told us that they had been supported to identify their learning needs and attend training to support them in their roles. We spoke with five junior doctors. They told us that they received appropriate supervision, had protected time for their study and speciality training and regular reviews.

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In theatres, new staff rotated through different theatres to gain experience of different specialities. Staff told us this ensured new staff were developed to support he emergency theatres as well as giving new staff the opportunity to find what surgery interested them the most. Staff looking after complex patients, such as those with tracheostomy, had additional training. This included face to face training, workbooks and competency assessments before they were deemed competent to safely care for those patients. Associate practitioners on Coltishall ward were also trained to care for tracheostomies. This was also the case in spinal surgery where the nurse practitioners would provide training to staff on the wards regarding care of spinal patients. Some wards had clinical nurse educators to support staff in clinical development. Easton ward had just appointed one to commence shortly after our inspection though not every ward had one. Staff spoke highly of the clinical educator role that supported students on placement, enabling them to develop skills and build confidence whilst giving them a named support. In interventional radiology, all staff attended three-hour training updates every quarter. All staff at Cromer had received an appraisal. Staff were supported to undertake training to support their role. Staff were rotated through different theatres to ensure they were competent to undertake the range of procedures that were carried out for example between ophthalmology and dermatology. The day unit had students and also apprentices who were supported in their roles by staff, clinical and non-clinical educators. At Cromer, a nurse registrar was carrying out procedures. This was a new role to develop already highly skilled staff with a pathway to a nurse consultant position.

Multidisciplinary working Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care. There were numerous examples of multidisciplinary working throughout our inspection. Ward, theatre and other clinical areas were supported by staff from a range of roles to ensure joined up patient care. We observed formal multidisciplinary working on ward rounds attended by doctors, nurses, physiotherapists and others who were all were respectful of others input to the discussion. Multidisciplinary working was clearly evident in discharge planning where professionals from a variety of backgrounds in health and social care worked together on sometimes complex discharges to plan a smooth discharge for patients. Specialty multidisciplinary meetings were held. This allowed senior doctors and other clinicians to discuss cases and agree on the most appropriate treatment. For some specialties there was also regional MDT’s where, via video link, cases would be discussed with other hospitals. This all allowed for effective communication for patients who may be referred in to the trust or referred out for specialist care. We observed examples of multidisciplinary working with staff from other organisations including community nursing staff and social workers in the planning of a complex discharge.

Seven-day services

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Most of the services offered seven-day services although the cover for services such as pharmacy and physiotherapy was reduced at weekends and bank holidays but could be requested. Urgent review of patients could be requested form chest physiotherapist for example. There were ward rounds at weekends and in orthopaedics these were consultant led. In part to address the backlog of patients in IRU, the unit was working weekends. This was planned to continue until the backlog was cleared and long waiting patients treated. It was being managed by staff doing additional shifts. This also applied to emergency patients who could be treated out of hours. Emergency theatres worked twenty-four hours a day on all days. Some services such as pharmacy offered an on-call service out of hours and weekends. Some services such as dieticians did not cover seven days. Surgery at Comer provided a Monday to Friday service.

Health promotion Patients were given information on health promotion pre- and post-operatively. This included smoking cessation, weight loss and healthy eating before and after surgery. We observed some literature around the trust concerned with the Expert Patient Programme where patients are given skills to self-manage their health conditions. Patients could be referred back to their GP for ongoing support or referral to specialist smoking cessation and other services. At Comer patients were given health promotion advice at the pre- admission clinic.

Consent, Mental Capacity Act and Deprivation of Liberty Safeguards Mental Capacity Act and Deprivation of Liberty training completion Staff did not always understand their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. Staff gave us inconsistent responses when asked about the Mental Capacity Act. The trust set a target of 90% for completion of Mental Capacity Act (MCA) and Deprivation of Liberty training. Qualified nursing staff were just under the trust training target for either of the training modules relating to the Mental Capacity Act (MCA) or Deprivation of Liberty (DoLS). A breakdown of compliance for Mental Capacity Act (MCA) and Deprivation of Liberty Safeguarding (DoLS) courses at September 2018 for medical and dental staff in surgery is shown below: Number Number of of eligible staff trained staff Completion Trust Met Name of course (YTD) (YTD) rate Target (Yes/No) Deprivation of Liberty Safeguards 220 338 65% 90% No Mental Capacity Act Level 1 219 338 65% 90% No

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Medical staff did not meet the trust training target for either of the training modules relating to the Mental Capacity Act (MCA) or Deprivation of Liberty (DoLS).

Norfolk and Norwich University Hospital A breakdown of compliance for Mental Capacity Act (MCA) and Deprivation of Liberty Safeguarding (DoLS) courses at September 2018 for qualified nursing staff in surgery at Norfolk and Norwich University Hospital is shown below: Number of staff Number of trained eligible Completion Trust Met Name of course (YTD) staff (YTD) rate Target (Yes/No) Mental Capacity Act Level 1 416 469 89% 90% No Deprivation of Liberty Safeguards 416 469 89% 90% No

Qualified nursing staff were just under the trust training target for either of the training modules relating to the Mental Capacity Act (MCA) or Deprivation of Liberty (DoLS). Note: The trust was unable to provide site level training data for medical and dental staff working in surgery. Staff we spoke with had a mixed understanding of the Mental Capacity Act 2005 (MCA). We had found this on previous inspections. Six staff we spoke with had a good understanding of the MCA and their responsibilities under it whereas another three staff confused the MCA with the Mental Health Act 1983 (MHA). The same six staff could describe the Deprivation of Liberty Safeguards (DoLS) and the process for using them. We reviewed the records of one patient who was subject to DoLS during our inspection. We found the appropriate records, decision and authorisation to be in place. All staff we spoke with could describe Gillick competence (which is concerned with a child’s capacity to give consent) and how they would apply it. They were able to access resources to support them in the decision making. Consent was gained from patients before any treatment was given. In 13 records we reviewed where patients had a procedure, all contained valid consent signed by the patient. Patients told us that they had been given sufficient information on which to make a judgement about whether to have treatment and were told the risks and complications of the procedure. We observed numerous occasions when verbal consent was requested for care activities and interventions such as taking blood pressure readings.

Cromer Hospital A breakdown of compliance for Mental Capacity Act (MCA) and Deprivation of Liberty Safeguarding (DoLS) courses at September 2018 for qualified nursing staff in surgery at Cromer Hospital is shown below: Number of staff Number of trained eligible Completion Trust Met Name of course (YTD) staff (YTD) rate Target (Yes/No) Mental Capacity Act Level 1 17 18 94% 90% Yes Deprivation of Liberty Safeguards 17 18 94% 90% Yes

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Qualified nursing staff met the trust training target for both training modules relating to the Mental Capacity Act (MCA) and Deprivation of Liberty (DoLS). Note: The trust was unable to provide site level training data for medical and dental staff working in surgery. (Source: Routine Provider Information Request (RPIR) – Training tab) Staff we spoke with at Cromer hospital had a good understanding of the MCA and DoLS. Patient consent was gained ahead of their procedure. This was either completed before admission and consent confirmed again before the procedure or shortly before the procedure in the case of minor procedures. We observed patients being given time to consider the procedure and ask any questions they had. Two consent forms we saw were fully completed and signed with benefits and risks of the procedure detailed.

Is the service caring? Compassionate care Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.

Friends and Family test performance From October 2017 to September 2018 the Friends and Family Test (FFT) response rate for surgery at Norfolk and Norwich University Hospital was 9%. A breakdown of FFT performance by ward for surgical wards at Norfolk and Norwich University Hospital over the same period is shown below.

5. The total responses exclude all responses in months where there were less than five responses at a particular ward (shown as gaps in the data above), as well as wards where there were less than 100 responses in total over the 12 month period. 6. Sorted by total response. 7. The formatting above is conditional formatting which colours cells on a grading from highest to lowest, to aid in seeing quickly where scores are high or low. Colours do not imply the passing or failing of any national standard. (Source: NHS England Friends and Family Test) FFT scores we saw in four ward areas showed latest scores were at 97% or greater for December 2018. Staff were committed to ensuring patients received the best care during their admission. We saw numerous occasions where staff were supportive of patients and taking time to speak to them. We

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 172 saw one occasion when a student nurse took time to reassure a distressed patient, made time to spend with them and spoke in a calm and assured manner. Relatives and patients, we spoke with told us that all staff had been caring and compassionate. Whilst a few remarked that staff were busy, they said that staff spent time with them and talked through any concerns they may have. All said staff were caring and kind when caring for them. At our last inspection we were concerned about privacy and dignity in the induction area of interventional radiology. At this inspection we saw that improvements had been made to the area to protect people’s dignity including a larger area, more appropriate curtains and less movement in a nearby corridor. Work was due to be completed in early 2019 to allow patients to be anaesthetised and recovered in the scanning room to further protect their privacy. In the main IRU the small environment meant that there were times when male and female inpatients were in close proximity. This was on the risk register and would be resolved on completion of the new unit in late 2019. At Cromer, FFT was consistently positive with the inpatient area scoring 98% or more for the preceding six months. We spoke with one patient who said the care they had received had been excellent. They told us staff had been kind and thoughtful and supportive to them during their procedure.

Emotional support Staff provided emotional support to patients to minimise their distress. Staff were aware of the emotional support patients required before and after surgery. There was support for patients from specialist areas. For example, specialist nurses working in general surgery and stoma care would meet with patients ahead of surgery to offer support and information. They would then offer ongoing support following surgery. Some patients who had surgery as part of cancer treatment also accessed services at the Colney Centre where they had access to support services. Whilst there were no counselling services provided directly, it was possible to refer some patients for counselling if it was felt to be beneficial. All patients we spoke with told us of the support they received from staff. One relative told us that staff offered emotional support to them during a difficult time. Staff were able to request chaplaincy support for patients or patients were able to contact chaplaincy independently. At Cromer, an additional member of staff was frequently used in theatre whose main focus was to keep the patient calm and offer support to them through the procedure.

Understanding and involvement of patients and those close to them Staff involved patients and those close to them in decisions about their care and treatment. Patients, relatives and their significant others told us that they were kept informed of their treatment and were involved with the plans for their care. All told us they had been supported to make decisions about their care, with one person telling us they ‘owned their care’. Records showed good communication with patients about their options about the progress of their care. 20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 173

At Cromer we observed staff explain procedures throughout keeping the patient involved and answering any questions. One patient told us that they had been given all the information they had needed to allow them to manage their care after discharge.

Is the service responsive? Service delivery to meet the needs of local people The trust planned and provided services in a way that met the needs of local people. The trust had undertaken initiatives that had reduced length of stay for some patients. The senior leadership team of the division were clearly focussed on providing care that met the needs of the local population and those that travel to receive tertiary services. The senior team told us they had a good relationship with the lead clinical commissioning group who they were in regular contact with. There was a focus on the redesign of care pathways across the Norfolk health and care system to ensure patients received high quality care. The division and the trust were engaged with the sustainability and transformation plan for Norfolk and Waveney. There had been work on clinical pathways within the region and without to ensure patients received treatment in the most appropriate place. This included some specialist services provided by the division at the Norfolk and Norwich Hospital which they were keen to develop. Divisional leadership were clear about the importance of working as a system and with other stakeholders to design effective, high quality services for local people. The division had implemented novel approaches to some care and treatment. For example, the Norfolk Stone Room offered on the day lithotripsy (a way of using ultrasound to break up kidney stones in a non-invasive way) on Edgefield ward. There was an emergency assessment unit surgical care on Easton ward. This pathway allowed patients to be referred for assessment to the ward thereby avoiding attendance at the emergency department. The IRU was significantly under sized for the size of the population and amount of activity required to meet the needs of the population. There were plans in place to increase the size of the unit to increase activity almost four-fold. The unit was due to open in late 2019. In the meantime, patients who were well enough were offered the opportunity of attending another unit for their procedure. However, this involved a trip to either London or Birmingham. At the time of our inspection no patients had used this service. Cromer hospital enabled local people to have minor procedures close to home. Minor procedures in dermatology, ophthalmology, plastics and gynaecology could be carried out at the hospital. Feedback consistently showed that local people valued the local service.

Meeting people’s individual needs The service took account of patients’ individual needs. There was a dedicated learning disability team that supported staff on the wards and in other clinical areas to care for people with complex needs. Staff could access the team who would then support with care planning.

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‘This is me’ documents were used to ensure patients living with dementia had an appropriate care plan and that staff knew how best to support their care and choices. Symbols were used on boards to indicate the different kinds of support that patients required. These were discreet yet conveyed important information to staff. Translation services were available through a telephone service. Four members of staff we spoke with knew now to access the service though none had needed to. Equipment was available on the wards and in theatres to care for bariatric patients and ensure they were able to receive treatment. Patients told us that staff appeared busy but that they were attended to promptly. Whilst most call bells were answered promptly we saw an occasion on Easton ward where a call bell rang for five minutes before being answered. In the DPU there were inpatients in the area that was designed for children. The area was being used for inpatient due to lack of capacity in the rest of the hospital. The DPU had been used as an escalation area since 6ht January 2019. This was the first time it had been used as an escalation area since 2018. This meant children requiring day procedure had to be admitted to the children’s ward rather than the DPU for their procedure. At Cromer there was facilities for people with mobility issues. However, the unit was on the first floor and there was a history of the only lift failing. The lift failed for two weeks in 2018 meaning people with limited mobility found it difficult or impossible to access the first floor. This concern was on the risk register for Cromer and steps had been taken to reduce the risk of recurrence including holding a stock of common parts. Patients who were unable to attend appointments had them rescheduled. There was access to translation services although we were told these were rarely required. Staff told us that it was not common to have patients with a learning disability or those living with dementia cared for on the unit. Patients with additional or complex needs were identified at pre- admission and would then be allocated to receive care at the best place suited to their needs.

Access and flow People could not access the service when they needed it. Waiting times for treatment and arrangements to admit, treat and discharge patients were not in line with good practice and worse than the England average. This was despite a full recovery plan being in place and agreed by stakeholders. The use of escalation areas impacted the functioning of clinical pathways. The day procedure unit and EAUS both had inpatients which negatively impacted activity in those areas.

Average length of stay Elective Average Length of Stay - Norfolk and Norwich University Hospital

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Note: Top three specialties for specific site based on count of activity.

Norfolk and Norwich University Hospital - non-elective patients The average length of stay for all non-elective patients at Norfolk and Norwich University Hospital was 3.4 days, which is lower compared to the England average of 4.9 days. • The average length of stay for general surgery non-elective patients at Norfolk and Norwich University Hospital was 3.4 days, which is lower compared to the England average of 3.8 days. • The average length of stay for trauma and orthopaedics non-elective patients at Norfolk and Norwich University Hospital was 6.7 days, which is lower compared to the England average of 8.7 days. • The average length of stay for urology non-elective patients at Norfolk and Norwich University Hospital was 2.0 days, which is lower compared to the England average of 2.8 days.

Non-Elective Average Length of Stay - Norfolk and Norwich University Hospital

Note: Top three specialties for specific site based on count of activity.

Cromer Hospital - elective patients From August 2017 to July 2018 the average length of stay for all elective patients at Cromer Hospital was 1.0 days, which is lower compared to the England average of 3.9 days. • The average length of stay for Urology elective patients at Cromer Hospital was 1.0 days, which is lower compared to the England average of 2.5 days.

Elective Average Length of Stay - Cromer Hospital

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Note: Top three specialties for specific site based on count of activity.

Cromer Hospital - elective patients Cromer hospital only has elective surgical activity so there are no non-elective lengths of stay. Cromer hospital saw day case, minor procedure cases only with no overnight beds. (Source: Hospital Episode Statistics)

Referral to treatment (percentage within 18 weeks) - admitted performance From October 2017 to September 2018 the trust’s referral to treatment time (RTT) for admitted pathways for surgery was worse than the England average. As of September 2018, 57.5% patients had RTT within 18 weeks at the trust compared to England average of 66.6%.

(Source: NHS England)

Referral to treatment (percentage within 18 weeks) – by specialty One specialty was above the England average for RTT rates (percentage within 18 weeks) for admitted pathways within surgery. Specialty grouping Result England average Ophthalmology 76.9% 67.8%

Six specialties were below the England average for RTT rates (percentage within 18 weeks) for admitted pathways within surgery. Specialty grouping Result England average Urology 64.8% 76.7% Plastic surgery 64.2% 80.9% General surgery 58.2% 72.6% Oral surgery 57.4% 59.1% ENT 47.8% 63.5% Trauma & orthopaedics 33.0% 59.8%

The trust continued to fail to meet the England average for referral to treatment times other than ophthalmology. Senior staff were well sighted on the challenge to address the backlog and had

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 177 detailed plans in place. They had increased capacity by increasing weekend activity and the use of a Vanguard theatre but operational pressures had continued to impact the amount of elective activity at the trust. There had been a 20% increase in emergency surgery in the preceding 12 months. Senor leaders told us this had impacted on the divisions ability to manage some elective surgery. However, despite some improvement in length of stay for some surgical specialities, the trust continued to perform poorly for RTT. A recovery action plan (RAP) was in place for RTT and had been approved by commissioners. There were actions for the trust to complete as well as those for other stakeholders such as commissioners. The plan had been approved by the lead clinical commissioning group in 2018. However, at the time of our inspection, RTT for most specialists was considerably worse than the England average. The weekly patient tracking list meeting monitored and discussed the RAP and performance required for improvement. The IRU had a significant backlog with 28 patients waiting longer than 52 weeks for treatment. All patients awaiting treatment had been risk assessed and prioritised accordingly. There was a standard operating procedure (SOP) in place to manage the backlog and the trust had committed to have no patients waiting over 52 weeks by the end of March 2019. Long waiting patients were to be offered their procedure in other centres if they wished but this may require a journey to London or Birmingham.

Cancelled operations A last-minute cancellation is a cancellation for non-clinical reasons on the day the patient was due to arrive, after they have arrived in hospital or on the day of their operation. If a patient has not been treated within 28 days of a last-minute cancellation then this is recorded as a breach of the standard and the patient should be offered treatment at the time and hospital of their choice From 2016/17 quarter two to 2017/18 quarter three, the percentage of cancelled operations where the patient was not treated within 28 days was consistently higher than the England average.

Percentage of patients whose operation was cancelled and were not treated within 28 days - Norfolk and Norwich University Hospitals NHS Foundation Trust

Cancelled operations as a percentage of operative activity was similar to England average apart from Q4 217/18 where is was higher.

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Cancelled Operations as a percentage of elective admissions - Norfolk and Norwich University Hospitals NHS Foundation Trust

(Source: NHS England) Since our last inspection there had been an increase in cancelled operations, predominantly over the winter of 2017/ 18. Whilst there had been an improvement during 2018 the trust continued to cancel more operations than the England average. Data showed that there had been a reduction in elective activity in December 2018 which was below plan but slightly better than actual activity for the same period last year. There had been an increase in cancelled operations in October 2018 to around 80 cancellations and this had reduced to a little over 60 cancellations in December. Easton ward was a combination of assessment area and inpatient area. There were 21 inpatient beds and the assessment area should have six trolleys in a bay and seven single rooms with a waiting area. At our inspection these areas were being used for inpatients with only a few rooms for assessment. This had an impact of slowing down the assessment of patients who attended the unit. We observed two patients complaining of long waits to see a clinician. Staff told us that having inpatients in the assessment area meant long delays for some patients attending for review. Staff ensured that patients with the most complexity were assessed first. Data showed that there were a large number of admissions to the unit via the emergency assessment pathway with 1341 patients being seen though the unit in December 2018. Staff told us they anticipated an increase in the number of patients attending the ward in the future although the December attendances was almost 200 attendances lower than those in July 2018 when staffing on the ward had been lower than planned. There continued to be delays in transferring patients from theatre recovery to critical care areas. The longest recorded delay was 31 hours in January 2019. The average delay for patients treated overnight was eight hours and average not including overnight patients was a little over two hours. There was an average of 40 delayed patients per month for the three months to December 2018. An SOP was in place for the assessment of recovery of patients (ARS tool) aimed to estimate recovery time allowing theatres to anticipate recovery time for patients and identify delays. It also provides guidance for the management of patients overnight and provided an effective way to thematically review delays in recovery. Staff told us that due to unpredictable emergency activity, the IRU was sometimes under pressure which resulted in cancelled procedures for elective patients. Cancellations had been reduced but year on year increases in activity meant that the unit remained under pressure with its limited capacity and environment issues,

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Main theatre utilisation had shown some improvement year on year. Overall utilisation was 81.9% against 80.6% the previous year. However, DPU utilisation was at 72.5% with the overall number of cases down by 136 compared to the previous year. This was in large part due to the unit being used to manage winter pressures. The DPU had been used as an escalation space since the 7th January 2019. There were 24 inpatients on the day of our inspection. This had an impact on the number of patients DPU could treat. Whilst some were able to be treated in other areas, there were also cancellations of day case patients due to insufficient capacity to care for them. Data showed that a total of 274 patients were ‘last minute’ cancellations in the DPU between 5th November 2018 and 4th February 2019. Bed moves at night were relatively few on surgical wards with around 10 per ward per month which was an improvement. The exception to this was the Emergency Assessment Unit Surgical (Easton) which averaged around 200 bed moves over night per month for the 12 months preceding our inspection. This was due to the nature of the assessment area which then transferred patients to specialty wards. We requested information for non-clinical bed moves out of hours but were told the trust does not record that information.

Learning from complaints and concerns Summary of complaints There remained delays in responding to complaints. Response times were not in line with local policy with only 40% being completed within 25 days. From October 2017 to October 2018 there were 245 complaints about surgery. The trust took an average of 30 days to investigate and close complaints, and 40.4% of the complaints were closed within 25 days. This is not in line with their complaints policy, which states that more than 50% of complaints should be closed within 25 days. All 245 complaints related to surgery at Norfolk and Norwich University Hospital. A table of complaint subjects can be found below. Number of Percentage of Core service complaints total complaints Communications 59 24.1% Appointments including delays and cancellations 41 16.7% Clinical Treatment - Surgical 41 16.7% Patient Care including Nutrition/Hydration 26 10.6% Admission, Discharge and Transfers 18 7.3% Privacy, Dignity and Wellbeing 12 4.9% Values and Behaviours (Staff) 10 4.1% Waiting Times 8 3.3% Trust Administration 6 2.4% Clinical Treatment - General Medical 5 2.0% Clinical Treatment - Anaesthetics 4 1.6% Other 4 1.6% Prescribing Errors 4 1.6% Access to Treatment or Drugs 2 0.8%

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Clinical Treatment - Dental 1 0.4% End of Life Care 1 0.4% Commissioning Services 1 0.4% Consent 1 0.4% Clinical Treatment - Obstetrics & Gynaecology 1 0.4% Total 245 100.0% (Source: Routine Provider Information Request (RPIR) – Complaints tab)

Number of compliments made to the trust From October 2017 to September 2018 there were 109 compliments within surgery. A breakdown by site and ward can be found below.

Norfolk and Norwich University Hospital Percentage of Number of Ward name/area total compliments compliments Day Procedure Unit Theatres 15 13.8% EAUS/Easton Ward 13 11.9% Same Day Admissions Unit 11 10.1% Dermatology Unit 10 9.2% Day Procedure Unit Wards 9 8.3% Denton Ward 8 7.3% Docking Ward 5 4.6% Edgefield Ward 5 4.6% Coltishall Ward 4 3.7% Nelson Day Unit 4 3.7% Dilham Ward 4 3.7% Gateley Ward 3 2.8% Main Theatres 3 2.8% Earsham Ward 3 2.8% Pain Management Team 2 1.8% Pre-Operative Assessment Unit 1 0.9% Anaesthetics Department 1 0.9% Interventional Radiology Unit 1 0.9% Total 102 100.0%

The time taken to respond to complaints had deteriorated since our last inspection and which was outside of the trusts timeframe within their complaints policy. Details of how to make a complaint were available on wards and throughout the hospital. Staff we spoke with told us the procedure they would follow if someone wanted to make a complaint. Staff were quick to talk about de-escalation and that many issues are solved quickly with good communication. They recognised however that some complaints needed to be treated formally and were supportive of that. Three patients we spoke with said they would feel comfortable to make a complaint and would know how to do so but did not have a complaint to make. Ward meeting minutes showed that complaints were discussed and any learning shared. The number of complaints a clinical area had received were displayed prominently on the ward. Senior

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 181 ward staff could tell us about the complaints or their area and any themes that arose from them. In one area, staff told us how they had improved communication with relatives, including more written materials following a complaint made from relatives. Complaints fed into the governance structure of the division and were discussed at divisional meetings. There was also recognition that complaints may also trigger an incident report or duty of candour requirement.

Cromer Hospital Percentage of Number of Ward name/area total compliments compliments Day Procedure Unit 4 57.1% Cromer Ophthalmology 1 14.3% Cromer Allies Ophthalmology 1 14.3% Cromer Muriel Thoms 1 14.3% Total 7 100.0% (Source: Routine Provider Information Request (RPIR) – Compliments tab) Oct. 2017 to Sept. 2018 Staff we spoke with at Cromer could describe the complaints process and how they would advise a patient who wanted to make a complaint. There had been no recent complaints about Cromer surgical unit.

Is the service well-led? Leadership The surgical division was led by a triumvirate of chief of division, director of nursing and director of operations. The divisional structure was introduced in April 2016. The chief of division had been in post for 12 months and the operations director in post since December 2018 so as a team were comparatively new. They told us that the structure had settled and that they were being given increasing autonomy to manage the strategy and business of the division. The leadership told us that they were making headway with their objectives but had also identified areas of support they required. They had taken the initiative to have external professional leadership coaching to develop their leadership skills. The triumvirate met informally weekly to ensure clarity and consistency of communication. Staff spoke highly of their local leadership in ward areas. They told us they were supported in their work and were able to raise concerns although after our inspection we received information that this was inconsistent across different areas. Ward managers we spoke with felt supported by their matrons and senior matrons for the division. Theatres had a new leadership team with the matron and senior matron acting into post since December 2018. They told us they felt a cohesive team and had a clear plan of the issues they wanted to address including challenging poor behaviours and improving the utilisation time of theatres. Theatre managers had instigated a daily team leader (DTL) who was responsible for the theatre they were working in that day. Responsibilities were laid out in a SOP and theatre managers said this had a positive impact on ownership whilst supporting the development of staff in theatres. The

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 182 division had recently appointed a chief of service for theatres who was helping develop leadership capabilities within theatres and the division. At our previous inspection we found that visibility of and communication from senior staff was not always good, particularly regarding the reconfiguration of wards and specialties. Staff on ward areas spoke positively about the divisional leadership and said they were supportive and visible. Staff also told us that the Chief Nurse was visible in clinical areas and around the hospital. Staff spoke highly of the ‘Matron of the day’ which had been recently introduced. Staff told us they found this to be supportive with a clear route for escalation if that was required. Divisional leaders had supported new medical service directors by ensuring they had exposure to and worked with senior executive management. This was to enable them to become effective leadership in their clinical directorate. Staff at Cromer spoke positively about the senior matron and local leadership. They also told us that executive leaders were visible and that the chief nurse had spent some time at the hospital understanding the services and speaking to staff. The senior matron for Cromer hospital attended the hospital once a month. However, staff at Cromer told us that divisional leadership was not as visible at the hospital.

Vision and strategy The division had a strategy for service improvement but this was not articulated by division staff. The trust had a clear vision to provide every patient with the best possible care. The trust values were PRIDE; People focussed, respect, integrity, dedication and excellence. All staff that we spoke with were aware of the trust’s values which were displayed prominently around the hospital. The divisional leadership described their vision and strategy. This was to ensure cancer, elective and non-elective surgery were balanced to ensure all patients had access to the right treatment at the right time at a tertiary centre. Staff we spoke with in the division were aware of the broader vision and strategy for the trust but not for the surgical division. The divisional leadership described work with the STP that impacted the division. This included integrating services such as ENT and urology with other NHS trusts and ensuring the pathways were clinically led, both medical and nursing. Staff at Cromer were aware of the wider strategy for the trust and the local strategy for Comer hospital but did not articulate the strategy for the division as outlined by the divisional leaders.

Culture There had been an improvement in the culture since our last inspection although further work was required to embed this. Not all staff felt the culture had improved. There had been significant work across the trust and division to promote a culture of openness and transparency. Prior to our last inspection there had been a series of whistle blowers contacting CQC but this had not happened prior to this inspection. Most staff we spoke with on- site told us they felt able to raise concerns if they had them and that they had confidence concerns would be addressed though not everyone in theatres felt this way. They told us the executive team

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 183 were more approachable than had been the case previously. However, shortly after our inspection we received information from two whistle blowers relating to surgical services who raised concerns about staffing, escalation, concerns about the site team and that staff were not being listened to. Other concerns included the management and flow of patients through the hospital, management support and staff morale. We remained concerned that not all staff were confident to raise concerns within the trust. The trust had a freedom to speak up guardian and had recently advertised for this to be a permanent position. The new guardian was due to commence work in March 2019 with a priority to raise the profile of the post. A number of ward staff said that the culture was improving and that incidents were now about sharing learning rather than sharing blame which had been a significant change. Senior staff in theatres told us that the culture had improved generally and that staff felt empowered to challenge and raise concerns. However more junior staff we spoke with gave a mixed response. One member of staff told us that communication had improved whilst others said that that there remained issues with communication. We were told by a number of junior staff that communication was either not effective or did not happen. Whilst change had been commenced in theatres it was clear that the ongoing cultural work was not yet embedded. Several staff we spoke with also told us that changes were implemented without staff being consulted or informed. Staff told us that, at times, they felt under pressure. This was due to an intense workload and that they occasionally had less staff than they were supposed to have. Others told us that it impacted morale when their clinical area was not used for its intended purpose such as in the day procedure unit or medical outlier patients on surgical wards. Morale had improved in some areas such as Edgefield ward. The ward had previously been urology and vascular but was now urology only although there were 13 medical outlier patients at the time of our inspection. Staff said they were busy but they felt more confident caring for urology patients and there had been better consultant engagement since the ward became a single specialty ward. However, following our inspection we received information that staff were still concerned about a lack of support on this ward from management and concerns about high number of medical outliers. Some staff reported an ongoing lack of challenge in theatres, for example if senior medical staff wore jewellery or nail varnish, junior staff did not always feel comfortable challenging them. One member of staff told us they believed that senior medical staff went unchallenged by management. Another member of staff in theatres told us that bullying could still be witnessed on occasion in theatres. Staff in the day procedure unit told us they refused inappropriate patients and were no longer pressured to admit patients who were not suitable to the environment. They believed the restructuring of the site team and the winter room meant that key people understood the issues for escalation areas and wouldn’t allocate inappropriate patients to the unit. In the IRU, staff told us they had been empowered to make the changes needed following our last inspection. They told us this had been a significant change in the last 12 months.

Governance

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The trust used a systematic approach to continually improving the quality of its services and safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish. There were processes and structures in place to manage the governance of the division and escalate issues, concerns or change to the board and other trust wide groups. The divisional triumvirate were accountable to the board. Under the divisional triumvirate were the clinical directorates grouped into clinical specialities. Two monthly meetings including the governance meeting and risk meeting reviewed performance and business along with audit, incidents, complaints and staffing. A summary performance report was fed up to the divisional board for review along with additional detail if required. The divisional board accounted for their performance to the trust executive board via the divisional performance committee. We were told that the committee structure and content were under review to further strengthen governance. The divisional board met monthly with the directorates to discuss risk and performance. It allowed directorates to raise concerns, as well as sharing learning and information. There was effective prioritisation of business, for example the need to replace equipment and other key issues that ensured divisional oversight. There was also oversight of divisional actions taken to meet requirements of the action plan created following our last inspection. The trust also had a cross division senior matrons meeting which was held monthly; allowed senior nursing staff to discuss risk and governance, measured progress against objectives and enabled information sharing. There was a further monthly clinical governance meeting attended by doctors and matrons within the division. There were governance meetings in IRU monthly with all modalities in diagnostic imaging having such meetings. These fed into the division responsible for the service. Leadership responsible for the IRU had developed a detailed action plan to address concerns we raised at the previous inspection as well as actions for the development of the unit. These were monitored as part of the governance meeting within the directorate. There were cross divisional meetings held bimonthly to consider performance and share information. Theatres held governance meetings monthly with a good attendance from staff. Cromer hospital formed its own directorate. This included the surgical aspects of care provided at the hospital along with outpatient services and other medical services. There had been a restructure since our last inspection with the ophthalmology theatre now working with the day unit. The directorate fed into the divisional structure as with other directorates including for risk management and governance.

Management of risk, issues and performance The trust did not have effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. Some risks had been on the risk register for some years without effective measures to address them. There had been ongoing issues with referral to treatment times, capacity, access and flow and staffing over a number of years that had not been fully addressed. There was a divisional monthly risk assessment meeting which considered risks within the division. This was attended by the divisional director of nursing, governance leads, matrons and

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 185 divisional operations managers. The meeting scored each risk. All risks scoring over 16 after mitigation were reviewed monthly along with all new risks. Scores of less than 16 were reviewed two to three monthly depending on risk. High scores over 16, or where judged necessary, were escalated to the divisional risk and performance meeting where they would be added to the divisional risk register. Divisional risks would then be added to the corporate risk register if necessary. The division had a risk register that was reviewed monthly. Division leadership were clear about the most serious risk in the division that were reflected on the risk register including risk of failure of sterilisation equipment and ageing defibrillators. The risk register showed actions and mitigations to reduce the risk as well the current risk score and the aimed for risk score. All risks had been reviewed. However, there were risks on the risk register, including a risk for the environment in orthotics and general surgery, which had been on the register for a considerable time. A risk had been identified in the orthotics department in relation to the environment had been on the risk register since 2012. The register stated that a quote for using a new room was still awaited. Another risk relating to the risk of patient deterioration when transferred around the hospital had been on the risk register since 2011. The latest update in December 2018 is that the divisional nursing director would discuss with trust wide colleagues. Other risks that had been on the register since 2016 included ageing patient ventilation equipment and frequent delays to the plastic surgery operating list as it followed an emergency list. We were concerned that there was insufficient traction to address and close long-standing risks. There was a surgical division integrated performance report which brought together key metrics in a single document. This was considered and reviewed by the division at monthly meetings and themes, areas of concern and performance addressed. These became actions for relevant senior staff. The integrated performance report was reflective of risk including issues such as mandatory training and records audits, however we found concerns persisted with these on this inspection and the issues had not been fully addressed. The most urgent patient safety concerns we identified at our last inspection, such as those in the IRU and the DPU had been addressed. This had been managed and tracked on an action plan with oversight from executives, regulators and other stakeholders. Whilst the safety issues had been mitigated there remained ongoing operational challenges that impacted on the activity in the division. This included an IRU that was not of sufficient size to meet demand and the DPU which had large numbers of inpatients thereby reducing the capacity for day case. Serious incidents were on the agenda for every governance and risk meeting in the division with significant concerns escalated to divisional board and then to trust board if necessary. Whilst work had been undertaken to mitigate risk and eliminate never events, the two further never events since our last inspection demonstrated that these measures were not yet fully embedded. The division regularly reviewed their referral to treatment time (RTT) backlog. There was a monthly clinical harm review of all patient overdue to assess for potential avoidable harms. It also enabled risk stratification so that patients who were at highest risk were prioritised for treatment. A recovery action plan (RAP) was in place for RTT and had been approved by commissioners. However, at the time of our inspection, RTT for most specialties was considerably worse than the England average. Some staff told us they were still uncomfortable to challenge senior leadership and staff, predominantly in theatres. Risk and safety meetings outcomes were fed back to staff in theatres through the 7.30am daily theatre leader meetings.

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Information management The trust collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards. Information was provided to the division to allow effective monitoring of performance and finance. The division compiled and considered a monthly integrated performance report. This detailed finance and performance metrics giving an overview of the division. This was interrogated at divisional board and by other board sub committees. The reports were sufficiently detailed to allow granular discussion of issues on individual wards. Ward dashboards were sent monthly to ward managers. These were discussed by the ward manager and matron and senior matron with oversight from divisional and trust leadership. Managers we spoke with had a good knowledge of their ward dashboard, the challenges and positive performance that was shown. Information at Cromer allowed the directorate and division to monitor the activity taking place and plan accordingly. Staff we spoke with had a good knowledge and understanding of the operational activity at the hospital.

Engagement The trust was improving engagement with patients, staff, the public and local organisations but further work was required to embed these changes. There was no formal talent identification or management plan in place for the division. Staff were increasingly engaged with the processes within the division. We were told that members of staff had been involved with the development of processes and procedures. One member of staff told us they had been involved with the standard operating procedure for the day procedure unit. They told us it had been beneficial to have a member of staff working on the unit developing the procedure, as they understood the implications for patient care. In IRU, a junior member of staff had been engaged to complete an action plan for cleaning in the unit. Staff in several areas told us that they had been increasingly involved with quality improvement. There were regular staff meetings on wards and clinical areas and minutes showed variable attendance. Meetings we reviewed were held bimonthly and had standing agenda items. Theatres had engaged with staff regarding the purchasing and replacement of equipment. A record of business cases prepared by theatres was displayed prominently in theatres for staff to see progress. A newsletter circulated around the division entitled ‘Sharing the learning’ gave details and information of incidents and good practice. There was no formal talent management programme in the surgical division. Senior leaders identified staff they believed had potential and supported them through more informal means to develop. Divisional leadership told us that valuing talent was linked to recruitment and ensuring the right people are recruited to the right role. Patient forum groups within the division had reviewed plans for the new IRU and were able to contribute comments and influence the design of the environment.

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There was a full public and patient involvement strategy at the trust. Originally written in 2016 this was due for review in December 2018. We were told that the review had commenced and it would underpin engagement moving forwards. There were local patient satisfaction surveys completed by different teams within the division. We were told that they showed a high level of patient satisfaction. At Cromer there were ‘Meet with matron’ sessions monthly that allowed staff to meet the senior matron, ask questions and receive updates. The friends of Cromer hospital were active and fully engaged with the hospital. For example, they had been involved with the plans for the redevelopment of part of the site to provide more day patient chemotherapy services. Local leadership had attempted a ‘Meet the matron’ for the public but it was poorly attended. It was planned to re run this session in the summer. The friends of the hospital had also been involved with the development of a pre and post operative DVD to show the patient pathway at Cromer.

Learning, continuous improvement and innovation The trust was committed to improving services by learning from when things go well and when they go wrong, promoting training, research and innovation. There had been new initiatives to engage staff at all levels of the organisation. Shortly before our inspection theatres had put QR codes (a sort of bar code) on resuscitation trolleys and difficult airway trolleys in theatres and DPU. These were scanned by the member of staff who was checking the trolley on that day. It allowed managers to see remotely if equipment had been checked and escalate if the checks were not recorded as complete. This ensured emergency equipment was ready for use. The surgical division had maximised the use of the urology robot for major urological cancer resection, and had demonstrated improvements in outcome and reductions in length of stay. Norfolk and Norwich University Hospital was the first trust in East Anglia to carry out robotic colorectal cancer surgery. A consultant surgeon was the first surgeon in Norfolk to be certified by the European Academy of Robotic Colorectal Surgery (EARCS) after completing a robust training and assessment programme.

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Critical care

Facts and data about this service The critical care service at Norfolk and Norwich University Hospital was collectively known by staff as the “Critical Care Complex” (CCC). The CCC consisted of 28 adult critical care beds over two locations within the hospital, providing level two (high dependency) and level three (intensive care) services. Level two patients require higher levels of care and more detailed observation and intervention. Level three patients require advanced respiratory support alone or basic respiratory support together with support of at least two organ systems. The main CCC unit has 20 beds, consisting of ten level two and ten level three beds. The Gissing High Dependency Unit (GHDU) has eight level two beds, and was a short walking distance away from the main CCC. Level two patients were nursed one nurse to two patients (1:2) and level three were nursed one nurse to one patient (1:1). The CCC included a critical care outreach team (CCOT) to support acutely ill patients in other areas of the hospital. The team was led by a band eight nurse supported by six registered nurses and a critical care consultant. They were available seven days a week between 8am and 8:30pm. The CCOT also provided training on the management of acutely unwell patients to staff throughout the hospital. There was also a cardiac arrest team, consisting of two registered nurses and six operating department practitioners. The team responded to hospital-wide cardiac arrest calls 24 hours a day, seven days a week. The CCC service accepted emergency and elective admissions. Services provided included level two and level three organ support and post-operative care for major cancer surgeries, including oesophageal, head and neck and abdominal/gynaecological; vascular surgery, spinal surgery and emergency procedures. Children of all ages were accepted to the CCC in an emergency, whilst being stabilised and awaiting transfer out to a paediatric intensive care unit (PICU) facility. This included neonates over five kilograms in weight. Children aged between 12 and 16 were also admitted following surgery, if enhanced care beyond the provision of the hospital’s dedicated children’s High Dependency Unit (Buxton ward) was required. The CCC was part of the hospital’s surgical division, led locally by a clinical lead who was a critical care consultant, a matron and an operations manager. There were ten critical care consultants, one of whom was a paediatric anaesthetist by background, five teams of nurses each led by a senior nurse (band seven), a clinical nurse educator, four physiotherapists, six operating department practitioners (ODPs), a research team, pharmacists, speech and language therapist, dietician and additional support staff. Between December 2017 and December 2018 there were 522 adult admissions to the CCC, of which 29 were emergency admissions for children and young people. There were no elective admissions reported for children and young people during this period. We last inspected this service in November 2015 where we identified a number of concerns including: lack of multidisciplinary input on ward rounds, insufficient medical and nursing staff on duty, and a lack of supernumerary nurse coordinator out of hours and no full-time dedicated pharmacist for the service. Patients also experienced delayed discharges and leaders did not feel supported by senior hospital managers.

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During this inspection on 22 to 23 January and 06 February 2019 we inspected the whole core service and looked at all five key questions. We spoke with 35 members of staff including the clinical lead and matron, doctors, nurses, senior managers, support staff, cleaners, a pharmacist, an ODP, students and physiotherapists. We reviewed the healthcare records of eleven patients and spoke with nine patients and relatives.

Is the service safe? Mandatory training The service provided mandatory training in key skills to all staff and made sure everyone completed it. The trust set a target of 90% for completion of mandatory training. A breakdown of compliance for mandatory training courses from September 2018 for qualified nursing staff in the CCC is shown below:

Number Number of of staff eligible trained staff Completion Trust Met Name of course (YTD) (YTD) rate Target (Yes/No) Adult Basic Life Support 120 124 96.8% 90% Yes Health and Safety (Slips, Trips and Falls) 117 124 94.4% 90% Yes Manual Handling - People 115 124 92.7% 90% Yes Resuscitation 112 122 91.8% 90% Yes Fire Safety 113 124 91.1% 90% Yes Medicine management training 111 124 89.5% 90% No Blood Transfusion 107 122 87.7% 90% No Venous Thromboembolism 107 124 86.3% 90% No Clinical Record Keeping 105 124 84.7% 90% No Equality and Diversity 105 124 84.7% 90% No Infection Prevention (Level 2) 103 124 83.1% 90% No Information Governance 96 124 77.4% 90% No

Records we saw during inspection showed that training figures had improved. 90.7% of nursing staff and 88% medical staff were compliant with mandatory training. The trust did not provide us with pre-inspection training records for medical staff in critical care. Staff demonstrated they followed the hospital’s sepsis policy and protocol, which they could access via the intranet. We also saw information about sepsis management for staff displayed on notices throughout the service.

Safeguarding Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it. The trust set a target of 90% for completion of safeguarding training. Safeguarding training was incorporated into staff’s mandatory training.

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A breakdown of compliance for safeguarding training courses at September 2018 for qualified nursing staff in the CCC is shown below: Number of Number of staff trained eligible Completion Trust Met Name of course (YTD) staff (YTD) rate Target (Yes/No) Safeguarding Adults (Level 2) 123 124 99.2% 90% Yes Safeguarding Children (Level 2) 107 108 99.1% 90% Yes PREVENT - Level 3 106 124 85.5% 90% No Safeguarding Children (Level 3) 4 16 25.0% 90% No

Training records we saw during inspection showed that compliance had improved as 99.3% of nursing staff and 87% of medical staff had completed level two, adult and children’s safeguarding training. 88.2% of nursing staff had completed level three children’s safeguarding training and 88% of eligible medical staff had. Level three training had therefore significantly improved. Staff could access the trust’s safeguarding policies and procedures via the staff intranet system. We found that staff had access to sufficient and up-to-date information to support them to manage safeguarding concerns effectively. There was a “Trust Guideline for Safeguarding Adults” version six dated January 2019. This policy made reference to The Care Act (2014), Mental Health Act (1983), Mental Capacity Act, Prevent, honour based violence and Female Genital Mutilation (FGM). We also reviewed the “Trust Guideline for Safeguarding Children” version nine dated August 2017. This policy also referenced relevant legislation and guidance. Staff knew what constituted a safeguarding concern, how to recognise different types of abuse and how to escalate concerns appropriately. They knew that the hospital had a dedicated adult and children’s safeguarding team and how to contact them. Staff gave us examples of how they had acted appropriately to safeguard people who used the service. This included a recent safeguarding incident which had happened involving a pregnant women and unborn child. Safeguarding assessments were not formally carried out for patients during admission. There was also no safeguarding alert system in place in patient’s electronic healthcare records (EHR) to alert staff of safeguarding concerns. However, following us raising this concern to managers we found that action had been taken. In February 2019 we saw a new mandatory safeguarding risk assessment for all admissions and a safeguarding alert tab had been introduced into the EHR system. Staff had not received training on mental health, learning disability and autism. However, records showed that training for mental health and learning disability had been planned for staff this year. All clinical staff received dementia awareness training as part of the mandatory training programme. There were arrangements put in place to ensure that patients at risk of suicide or self-harm were kept safe. Staff were able to describe to us past incidents where they had cared for patients who were at risk of self-harm and how care was provided in line with the trust policy and procedure. This included environmental and ligature risk assessments which staff said they carried out. Staff were aware of the Mental Health Act (1983) and the sections of this legislation which related to doctors and nurse’s holding power. A consultant gave us an example where they had used their holding power to keep a patient who was at risk of self-harm safe. They described how urgent

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 191 advice had been sought from the trust’s mental health crisis team and that this team were, “very responsive to referrals”. We checked the service’s “standard operating procedure (SOP) for the use of patient safeguarding mittens in adult patients in the critical care complex” dated January 2019. The SOP stated that “patient safeguarding mitts are the only form of physical restraint to be used, at present, for patients in CCC/Gissing HDU”. Hand control mittens are a product designed in order to restrict the movement of one or both patient hands. Staff told us use of these mittens was in accordance with the trust procedure. We reviewed the CCC’s treatment algorithm for rapid tranquilisation dated January 2019. This algorithm was embedded in the EHRs. There was also a prompt in these records reminding staff to complete a mental capacity assessment for the patient prior to commencing pharmacological treatment.

Cleanliness, infection control and hygiene The service controlled infection risk well. Infection, prevention and control training was mandatory for all staff. Records showed that 90.7% of nursing and 88% of medical staff had completed this training. Staff decontaminated their hands before and after episodes of care and when entering and leaving clinical areas. We observed the entrance of the main CCC for twenty minutes. We saw that all staff decontaminated their hands with hand gel upon entering the service. Staff also adhered to bare below the elbows rules. There were sufficient hand gel dispensers, hand washing facilities and personal protective equipment (PPE) throughout the CCC. We saw staff using PPE appropriately. At each clinical entrance, large yellow notices were displayed reminding staff and visitors to clean their hands. Hand hygiene audits were carried out monthly. We checked the audit results from August 2018 to January 2019. Results showed 100% of staff were compliant with hand hygiene requirements for all months except November which was scored at 96%. Patients who were at risk of infection were cared for in side rooms to prevent spread of infection. There were also strict infection control measures in place which staff followed. During our inspection one patient was at risk of Methicillin Resistant Staphylococcus Aureus (MRSA) due to recently being transferred from another hospital. We saw that they were being cared for in a side room with isolation notices displayed on the entrance. Staff wore an apron and gloves when entering the room and decontaminated their hands when leaving. There were four side rooms on the main CCC unit available for the respiratory isolation of patients. These rooms had an appropriate airflow system in place to ensure adequate ventilation. Airflow could be changed from positive, negative or neutral. Data from between December 2017 and December 2018 showed that there had been two Clostridium difficile, three Klebsiella, three Methicillin Resistant Staphylococcus Aureus (MSSA) blood stream and one Pseudomonas infections reported by the CCC. Cleaning staff were contracted through an external provider. One member of cleaning staff was allocated to Gissing HDU and two to the main CCC unit daily, seven days a week. We saw cleaning staff carrying out cleaning duties throughout our inspection. There were also robust cleaning schedules in place which cleaning staff followed.

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Bed spaces were deep cleaned between patients when there was a high risk of infection. Deep cleaning is additional and thorough cleaning. This cleaning was carried out by a specialist team of cleaners and could be booked via the hospital switchboard. Staff told us that the team were quick to respond when contacted. There were curtains around each bed space. We saw a schedule showing curtains were changed three monthly routinely or before if contaminated. However, we also saw that curtains were made of a silk-like consistency and were not disposable. This meant the service was not meeting The Department of Health’s Health Building Note 04 -02 for critical care units. Following us raising this concern to managers we found that appropriate action was taken. This included managers escalating the issue to the trust’s estates department for review. Equipment and the environment were visibly clean. We checked 25 pieces of equipment. We saw that all equipment had dated “I am clean” green stickers on showing it was clean and ready to use. There were also cleaning schedules in place for equipment cleaning which we saw staff follow. A recent “Critical Care Flu Fighter Campaign” had been carried out whereby a group of nurses from the CCC offered staff flu vaccinations. Records showed that this campaign led to 90% of CCC staff being vaccinated by December 2018. There were effective systems in place for the safe management and disposal of waste products. Each bed space had a clinical waste and sharps waste bin next to it. There was also a functioning sluice within the centre of the main CCC unit and a separate sluice for Gissing HDU, both with pharmaceutical waste bins in.

Environment and equipment The service had suitable equipment and looked after it well. However the environment was not fit for purpose for children and young people. The CCC was a purpose built modern facility. The service ensured the facilities conformed to professional standards through numerous governance arrangements, including peer review. The CCC was located on level three within the East Block of the hospital which was within suitable proximity to the emergency department, theatres and radiology. All areas of the CCC were well organised, clear of clutter and large enough to provide safe care. Entry to the CCC was secure and strictly via an intercom entry system and staff key card access. We observed these systems be used consistently. Sharps bins throughout areas were readily available, clearly labelled and not overfilled. We saw that waste was labelled and handled appropriately. There were two whole time equivalent (WTE) housekeeping staff dedicated to the CCC. They managed stock to ensure that a range of essential supplies were in place for the service. We saw that there was a sufficient amount of equipment available including syringe drivers, ventilators and nasal gastric feeding pumps. Staff we spoke with confirmed this. Managers told us that they could access bariatric equipment and promptly through an external contractor. They gave an example of when they had done this in the past. There was a program in place for the routine replacement of capital equipment which was headed by a trust board. Records showed that equipment was replaced as required. For example, we saw

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 193 that five new defibrillators had been ordered and arrived for the CCC due to other defibrillators coming to the end of their working life. Maintenance schedules were in place for all equipment and were carried out by an external contractor. There was also a service level agreement (SLA) with a specialist external contractor for the maintenance of haemodialysis equipment. We checked the maintenance records for 20 pieces of equipment. This included ventilators, a blood glucose machine and syringe driver. Records showed that equipment was up-to-date with servicing requirements. Staff told us that they had received appropriate training for equipment they used. They also explained that when new equipment was purchased for the CCC they often received specialist equipment training. There was an equipment competency register we saw which the clinical nurse educator (CND) had oversight of. The register showed staff who were competent with the use of different types of equipment including, air mattresses, syringe drivers and a patient hoist. Records from 01 and 23 January 2019 showed that resuscitation and difficult airway management equipment was checked daily. A tag was used to secure this equipment making it tamperproof. There were also electronic system in place which showed when resuscitation equipment had last been checked and opened. At the beginning of each shift nursing staff were responsible for completing a thorough check of bedside equipment for their allocated patient. We observed this happen and one member of staff talked us through the process fully. There was no dedicated child-friendly area within the CCC where children and young people were cared for. Staff told us they tried to ensure that children and young people were cared for in side- rooms, however, that this did not always happen. This meant that children and young people were not protected from visual and audible situations which could be distressing. However, following us raising this concern managers were taking prompt action to improve this. By 06 February 2019 meetings had already taken place to temporarily allocate certain side rooms suitable for children and young people, with appropriate décor such as window stickers and calming light projectors being arranged. A manager also told us that when the next refurbishment of the CCC takes place there would be a dedicated and appropriately placed side room would be configured for children and young people.

Assessing and responding to patient risk Staff completed and updated risk assessments for each patient. However, the Critical Care Outreach Team (CCOT) was not available at all times. The CCOT supported acutely ill patients in other areas of the hospital prior to their transfer to the CCC, followed up on patients discharged from CCC as required and supported ward staff with patient tracheostomy care. The CCOT was led by a registered nurse (band eight) and consisted of six experienced registered nurses and a critical care consultant. The team were available between 8am and 8:30pm seven days a week. Outside of these hours the hospital at night team assessed deteriorating patients and liaised with the CCC as required, when requested by ward staff. The hospital at night team consisted of three registrars and five junior doctors. The Guidelines for the Provision of Intensive Care Service (2015) states: “Each hospital should be able to provide a Critical Care Outreach/Rapid Response Team that is available 24/7”. Managers confirmed that

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 194 there were no agreed plans in place to ensure a 24 hour, seven day a week, CCOT/Rapid Response Team. This meant that the service was not adhering to national recommendations for critical care services. This same concern had been raised during peer review process in 2017. There was a statement of purpose (SOP) in place for the CCOT which managers told us was under review. This was due to the team trialling a new shift pattern and records showed the SOP would be updated after the trial in March 2019. We asked the trust to see the SOP for the hospital at night service, however, this was not provided. Therefore we could not be sure an SOP was in place. There was a hospital-wide approach for the detection of the deteriorating patient and a documented escalation pathway. The service used a modified Early Warning Score (EWS) system for adults and an adapted EWS for children and young people. Records showed that the trust was in the process of trialling and adopting the “National Early Warning Score 2 (NEWS2)”. A manager told us that NEWS2 would be introduced hospital-wide in early March 2019. This was in line with the NHS England aim “for all acute hospital trusts and ambulances trust to fully adopt NEWS2 for adults by March 2019. The CCC staff newsletter dated January 2019 reminded staff to complete their e-learning for NEWS2 and provided an electronic link to this training. We saw staff respond promptly to patient risk. We tracked two patients from the ward areas that were triggering high EWS during our inspection. We found EWS were used and escalated appropriately, in line with the hospital’s graded clinical response strategy. There was also an emergency situation on CCC where a patient deteriorated in HDU. We observed this patient’s care was managed effectively, with support immediately available from senior medical staff. EWS audits were carried out six monthly within the CCC. Results from November 2018 showed 80% of ten patients discharged to a ward from CCC had a printed copy of their recent CCC observations and had their last set of observations out onto the ward observations chart. This was against a 90% target. Records showed that appropriate action had been taken following these audit results being lower than expected. This included an email sent to all staff reminding them about the process. There was a lead consultant and nurse in charge for the CCC who was available 24 hours a day, seven days a week. This ensured that there was appropriate critical care liaison available in the event of a patient requiring transfer or input from the critical care service. We checked the electronic healthcare records (EHR) of 11 people who had used the service. We found that comprehensive risk assessments were carried out for all patients, with appropriate risk management plans in place developed. Care was planned in line with best practice and national guidelines. For example, all of the 11 patients had daily venous thromboembolism (VTE) assessments completed since admission and were provided with VTE prophylaxis where required (National Institute of Health and Clinical Excellence, Venous thromboembolism in adults: reducing the risk in hospital, Quality Standard 3, 2018). During our inspection two patients had been admitted to the CCC with sepsis. We saw that both patients had received antibiotics within one hour of the sepsis being suspected and that sepsis bundles were in place. This was in line with the trust’s management of sepsis procedure. A care bundle is a group of interventions that, when used together, significantly improve patient outcomes.

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There was lead for sepsis within the trust who staff knew. Staff showed us how they were able to access up-to-date information on sepsis via the intranet. Trainee doctors confirmed they were competent and supported in the performance of invasive procedures. One doctor told us, “yes we are very well supported with invasive procedure training, consultants are great here”. A consultant also described the robust arrangements in place to ensure that trainee doctors were well supervised when learning and carrying out invasive procedures. The majority of staff we spoke with told us that they had not received conflict resolution training. However, records showed that trust-wide conflict resolution was planned for 2019 and the CCC had recently been offered training dates. A manager confirmed that all staff were required to complete this. The service did not monitor how many patients were admitted within four hours of decision to admit. However, as of November 2018 the CCC had changed this target from four hours to one hour. Records showed that data for this new target was being collected and an audit was scheduled for May 2019. Staff across the service told us there were no issues with admission delays. A standard operating procedure (SOP) was in place for, “The management of bed capacity issues within the CCC”. This SOP was dated October 2016 with a three year review date. It showed that two additional level two beds could be provided and staffed, in the recovery area of main theatres if CCC capacity was reached. Records from December 2018 to December 2019 showed eight level two patients were cared for and discharged via recovery due to a lack of capacity in CCC. Of these eight patients seven stayed overnight. There was a major incident box on the CCC. Service leads knew the box location and its content, including action cards for different staff types. There was a major incident lead for the CCC who was a registered nurse (band seven). We saw up-to-date paper copies of the trust major incident plan available throughout the CCC. Staff told us they had not received any formal training for major incidents. However, they were able to tell us what action they would take in the event of emergencies in line with local procedure. This included fire evacuation plans which were printed and visible throughout the service. Staff confirmed that weekly mains power testing happened to check the back-up generator system for the CCC. A manager told us that all ventilators had additional back-up power. We asked to see the SOP for emergency admissions for children and young people to the CCC. However, this information was not provided. SOPs provide accurate and detailed instructions on how to perform a defined process or procedure to ensure consistency and standardisation. The absence of this document meant we could not be assured that a defined process of procedure had been agreed.

Nurse staffing The service had enough nursing staff, with the right mix of qualification and skills, to keep patients safe and provide the right care and treatment. At our last inspection in 2015 we found that nursing staffing numbers did not meet national “Guidelines for the Provision of Intensive Care Services” (2015). In January 2019 we found that

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 196 whilst nursing numbers had improved significantly the vacancy rate and unfilled shift rate remained high. The total planned nursing establishment for the CCC was 154.9 WTE. In January 2019 the actual nursing establishment was 130.2 WTE showing a staff vacancy rate of 16%. The vacancy rate at band five was15%, band seven 34% and healthcare assistants was 55%. There were no band six or band 8 vacancies for the service. We checked the staffing rota for nursing staff from December 2017 to December 2018. This showed that on average 86.3% of planned registered nurse shifts and 84.9% of planned healthcare support worker shifts were filled. On average per month this meant that 13.6% or registered nurse shifts were not filled. Staffing numbers for the CCC were reviewed daily. We saw that where nursing shifts were not filled the acuity of the CCC was reviewed with level two bed closures made as required. We observed four bed closures happen on 21 January 2019 due to low staffing numbers. Managers told us that bed closures were a temporary measure to ensure staff to patient ratios were met. The set staff to patient ratio was 1:1 for level three and 1:2 for level two patients. We found that these regular bed closures resulted in a high number of cancelled elective operations. A manager confirmed this. From December 2017 and January 2019 there had been 88 cancelled elective operations (7.2%) due to insufficient beds available in CCC. Records did however show that managers were in the process of calculating and reconfiguring nursing establishment. This was subsequent to the new matron commencing employment. A manager also confirmed there had been difficulty recruiting nursing staff to the CCC despite continuous recruitment cycles. We saw that this recruitment challenge was being evaluated as part of this staffing analysis. In 2015 we raised concern about the lack of supernumerary nurse coordinator out of hours (OOHs). In 2019 we found that no action had been taken. A manager confirmed our finding. Staff throughout the service raised this as a concern with us. This meant that the service continued not to meet the “Guidelines for the Provision of Intensive Care Services” (2015) standard which states: “there will be a supernumerary clinical coordinator (sister/charge nurse bands 6/7) on duty 24/7 in critical care units”. We also found that this known risk was not on the service risk register. However, when we returned on 06 February 2019 we saw that this risk had been added to the risk registered and was being actioned appropriately. We saw that the concern had been escalated to senior hospital managers. At the main CCC entrance a notice board displayed planned compared to actual staffing numbers for the day/night. Planned CCC staffing numbers per shift were 19 registered nurses including the coordinator. There was also a matron (Band 8a) who worked four days a week between Monday and Friday. We observed that level three patients were nursed 1:1 (one nurse to one patient) and level two 1:2 (one nurse to two patients). Staff from across the service told us that this ratio was consistent and staffing for patients was safe. The CCC had a clinical nurse educator in post that worked 32 hours per week and was supported by another registered nurse six hours per week. The CCOT team consisted of a team of six experienced critical care nurses, led by a Band 8 nurse. Hospital ward staff called the CCOT when a patient was triggering a EWS of four or more.

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There was 24 hour access to a registered nurse (children’ branch) via the children and young people service. Staff told us that the paediatric team reviewed all children admitted to the CCC regularly. A manager confirmed that CCC staff, “endeavours to get a Buxton ward children’s nurse for each paediatric admission” to the CCC. Staff we spoke with confirmed this happened where possible. From October 2017 to September 2018, the CCC reported a turnover rate of 9.4% for qualified nursing staff. This was lower than the trust target of 10.0%. The CCC reported a sickness rate of 4% for qualified nursing staff between December 2017 to December 2018. This was slightly above the trust target of 3.5%. Bank and agency nursing staff were used regularly. However, records confirmed that the CCC did not utilise greater than 20% of registered nurses from bank/agency on any one shift when they were not their own staff. Managers told us that bank staff where staff already working on CCC and that agency staff were all “known” and were critical care nurses from another NHS trust. Induction packs for the CCC were available for bank and agency staff. We checked three agency staff at random and found they had completed this pack. There was a standardised handover procedure for shift handovers and patient discharges from the CCC. Staff were seen to communicate effectively with one another during handover procedures. We checked the daily patient handover document for 23 January 2019, which was up-to-date and contained all necessary patient information. The CCC research team consisted of one registered nurse (band six) who worked 30 hours per week, supported by another nurse (band 5) who worked eight hours per week. Both nurses were experienced critical care nurses. The team managed the research elements of the service which fed in to the national clinical trials the CCC was involved in.

Medical staffing The service did have enough medical staff, with the right mix of qualification and skills, to keep patients safe and provide the right care and treatment. In 2015 we found that there were insufficient numbers of medical staff employed for the service. At this inspection in 2019 we saw that there had been significant improvements made and that medical staffing now met Guidelines for the Provision of Intensive Care Services (2015). There was a chief of division for the service who was a consultant intensivist by background. They had been in post for one year at the time of our inspection. There were a further 10 consultant intensivists of whom two had gained a diploma in intensive care medicine and one was a paediatric anaesthetist. Patient care was led by consultant intensivists consistently. Between Monday and Friday during day time hours, three consultants worked each covering one of three areas of the CCC. At the weekend two consultants worked to cover the entire CCC service. Out of hours (OOH) there was a consultant on call 24 hours a day, seven days a week. Staff confirmed that all consultants were able to attend within 30 minutes when called. Consultants told us that when they were on duty they were dedicated to the critical care service only. Records showed that a business case had been improved to employ an additional eleventh consultant intensivist. A manager told us that this post was due to go out to advert in February 2019 with an aim to recruit a consultant with a background in medicine.

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The CCC had a full complement of medical trainees and therefore no trainee vacancies. There were 15 medical trainees in post. The service had also recently accepted foundation year programme (FY3) doctors, with three junior doctors due to start in August 2019. Each day shift there were four to five medical trainee doctors on duty to cover the CCC. After 7:30pm the night shift took over consisting of a senior and junior medical trainee doctor. At least one, or both, of these doctors was trained in advanced airway management. There was also on call support from a consultant intensivist out of hours. There were six operating department practitioners (ODPs) who provided a 24-hour, seven day a week service to support the CCC medical team. There were three associate critical care practitioners (ACCPs) in training. This was trust funded training. The ACCPs were all due to complete training and be part of the medical rota in 2020. Out of hours the CCC medical team carried the hospital cardiac arrest bleep. When the bleep alerted one of the CCC doctors on duty and an ODP would attend the call along with other staff. Doctors told us that there were also four tiers of anaesthetists on call who could attend the arrest call as required. Medical staffing rotas from November 2018 to 22 January 2019 showed that medical staffing numbers were as planned. We saw that there were a sufficient number of consultants employed to ensure that twice daily ward rounds happened. Staff told us that medical staffing was always good. Medical staffing rotas also showed that patients, including children, had immediate access to a practitioner who was trained and skilled in advanced airway techniques. Staff told us that locum and agency medical staff were not used. The medical staffing rotas we checked confirmed this. There were no vacancies for medical staffing for the CCC service. Between December 2017 and December 2018 the staff turnover rate for medical staff was consistently below the trust target of 10%. In December 2018 turnover rate was at its lowest (1%) and June 2018 had the highest rate (6.4%). Between December 2017 and December 2018 sickness rates for medical staff were significantly below the trust target of 3.5%. A robust handover document was completed by the medical team for all patients discharged from the CCC. We checked the handover procedure for one patient who was stepped-down to a ward in the hospital during our inspection. This handover was concise and contained all necessary information, including information about the patients’ mental health needs and emotional wellbeing. Medical handover took place at 7:30am and 7:30pm daily and each patient admitted to the CCC was discussed. Staff told us that handover was attended by consultants, all medical staff, lead nursing staff and ODPs. The medical handover also incorporated the recently introduced “safety huddle” where the matron and CCC clinical coordinator attended to discuss the service capacity, staffing and risk.

Records Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date and easily available to all staff providing care.

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The service used an electronic healthcare record (EHR) system specifically designed for critical care. Only authorised staff had access to this system which was password protected. Patients past medical history notes were kept in cabinets securely in each area. We checked the EHRs of nine patients who were admitted to the CCC and for two who were under the care of CCOT. All EHRs were accurate, complete, legible and up-to-date. For admissions, we saw that the time and decision to admit to the CCC was recorded, with formal handover documented. Computers were locked throughout the service when they were not in use. There was a critical care assessment proforma in place for all admissions. This was completed electronically by referring medical staff, following discussion with a CCC doctor. EHRs showed that patient’s needs were assessed on admission to the CCC. Staff told us that these assessments ensured that patients with pre-existing mental health conditions, learning disability, autism and, or, dementia were identified. Staff told us that when a patient had been seen by a member of the mental health liaison team, their mental health assessment, care plan and risk assessment was accessible to authorised staff on the EHR system. Two staff were responsible for electronic patient data collection and data upload to the Intensive Care National Audit Research Centre (ICNARC) database. Records showed that a, “Business case is being looked into”, as a, “Data analyst [for ICNARC data upload] should be recruited for every 600 patients”. We have 1800 patients and only 2 members of staff”. This meant that the service was not meeting ICNARC recommendations. However, managers told us that a business case was being developed for this and that the service was up-to-date with submissions.

Medicines The service followed best practice when prescribing, giving, recording and storing medicines. In 2015 the CCC did not employ a dedicated full-time pharmacist. In 2019 we found there was still no dedicated full-time pharmacist in post. However, there was an allocated pharmacy team who provided a basic pharmacy service. This was for two and a half hours per day, Monday to Friday, with additional pharmacy support available at the weekend. The lack of dedicated pharmacy staff was recorded on the service risk register. Records also showed a business case had been agreed to recruit a dedicated pharmacy team. The team was to include a WTE band 8a and WTE band 7 pharmacist and a part-time band 5 pharmacy technician. A pharmacy manager for the trust told us that they were in the process of recruiting to all these posts with aim to fill them by April 2019. 47 medicines incidents had been reported by the CCC between December 2017 and December 2018. Two of these incidents were graded as “medication incidents with potential to cause harm” with the other 45 graded as “no harm”. Managers told us that the majority of incidents were to do with computer errors whereby staff were using two electronic prescription systems, one of which the ward staff used and CCC staff were not familiar with. We saw that necessary action was being taken following these reported incidents. This included the provision of staff training on the trust- wide electronic prescribing system. Records showed that some staff had completed this already. Managers also told us that when the dedicated pharmacy team were recruited they expected this would provide mitigation against such incidents. 20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 200

We observed staff administer medicines in line with the “Nursing Midwifery Council’s (NMC) Standards for Medicines Management”. We reviewed the medicine records for seven people who used the service and found that allergies were clearly documented, prescriptions were readable and signed, and administration and route of administration were also clearly recorded. Medicines were stored securely behind locked doors in a medicines room, with the lead nurse holding the keys. We checked two controlled drug cupboards and found these medicines were in date, all accounted for and checked daily between 01 January and 23 January 2019. We also randomly checked 30 stock medicines throughout the service. We saw that packaging was intact, medicines were in date and stored according to the manufacturer’s recommendation. Records from 01 January and 23 January 2019 showed that the fridge in the main CCC unit was checked daily and temperatures were within set parameters. This fridge was used for medicines storage and kept in the medicines room. Throughout the service we saw that medical gases were stored safely and in line with the trust’s policy and procedure. Patients that were prescribed antimicrobials had a microbiological sample taken as required and treatment was reviewed when results were available. During a multidisciplinary team meeting (MDT) we saw doctors discussing patient’s antimicrobial samples and taking advice about antimicrobial prescription from the microbiologist present. We checked the antimicrobial prescriptions of six people who used the service and found that clinical indication, dose and duration of treatment was documented in their clinical notes.

Incidents The service managed patient safety incidents well. Never events are serious incidents that are entirely preventable as guidance, or safety recommendations providing strong systemic protective barriers, are available at a national level, and should have been implemented by all healthcare providers. From November 2017 to December 2018 the CCC reported one incident classified as a never event. The never event was reported due to failure to recognise a misplaced nasal gastric tube (NGT) and administering feed down a misplaced NGT. From November 2017 to December 2018 the CCC reported five serious incidents (SIs) which met the reporting criteria set by NHS England. The breakdown by incident type was as follows: pressure ulcers (five), treatment delay (one) and medical equipment/ devices/disposables (one). We reviewed the Root Cause Analysis (RCA) reports for the Never Event and last three SIs which related to pressure ulcers. We found that incidents had been investigated appropriately with corresponding action plans in place where action needed had been identified. Staff throughout the CCC told us that they were aware of the NGT incident and knew what had changed in practice as a result. Changes in practice included robust safety checks called Local Safety Standards for Invasive Procedures (LocSSIP’s) for NGT insertion and use. Medical new starter inductions for the CCC had also been amended to ensure awareness of the NGT LocSSIP’s and an associated e-learning module was available.

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Mortality and morbidity was reviewed monthly during quality, performance, risk and governance (QPRG) meeting. We checked the minutes from these meetings from November 2018 to January 2019. They showed that mortality and morbidity was reviewed sufficiently and that meetings were well attended. We did however find that some sections in meeting minutes were empty under the heading mortality and morbidity. However, staff confirmed that this subject was always discussed at QPRG meetings. From December 2017 and December 2018 there had been 357 incidents reported by the CCC. Implementation of care or ongoing monitoring review recorded (217), medication (47) and treatment/procedure (17) being the most frequently reported. During this same reporting period we randomly checked ten of the incidents reported as, “Implementation of care or ongoing monitoring review recorded”. We found that these were all no harm incidents, which staff had raised due to a patient requiring ongoing monitoring because of a new identified risk. For example, one incident was reported because a patient had a peripherally inserted central catheter (PICC) line which had started to look infected and another patient had a non-blanching area on ear. Staff demonstrated they understood their responsibilities to raise concerns, to record safety incidents, concerns and near misses. They knew how to report these appropriately using the hospital’s electronic incident reporting system. Staff also told us they received feedback from incidents they had reported. Lessons were learnt following incidents, with necessary action taken as a result of investigation when things went wrong. For example, 12 new pressure ulcers had been reported by the CCC between October 2017 and October 2018 which was the highest rate of pressure ulcers in the trust. Subsequently the CCC clinical nurse educator had attended the NHS Improvement project called “Stop the Pressure” and disseminated learning from this to staff. We saw that this had led to new equipment, including nasal cannulas, and staff had received training sessions on pressure ulcers. There were also notice boards within the CCC with information about pressure ulcers and how to reduce them. Staff told us that since these changes in practice the service had seen a marked improvement in hospital acquired grade two pressure ulcers being reported. Records confirmed this. From October 2018 to December 2018 records showed there had been no grade two pressure ulcers reported and one grade three. We saw that lessons learnt were shared to make sure action was taken to improve safety, including beyond the CCC service. We saw notices titled, “Key messages from incident learning” displayed throughout the CCC. One key message reminded staff about how to position patients following spinal aesthesia. Notice boards throughout the CCC displayed the trust’s “Surgical Division Top 3 Risks”. This reflected action being taken to mitigate risk following lessons learnt trust-wide. Staff we spoke with demonstrated they understood their role and responsibility in terms of the Duty of Candour (DoC). The DoC is a regulatory duty that relates to openness and transparency. It requires providers of health and social care services to notify patients (or other relevant persons) of certain notifiable safety incidents and provide reasonable support to that person. Records showed that DoC training was covered in the trust’s root cause analysis (RCA) training. All managers we spoke with confirmed they had either completed this training or had a date booked.

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We saw that DoC had been considered in each of the four RCA investigations we checked. There was also evidence to show that DoC legal duties had been met where required. There were notices throughout the service which informed staff about external safety alerts, recalls and reviews. On the main CCC one notice we saw related to a recent external safety alert regarding the management of life threatening bleeds from arteriovenous fistula. Staff told us that they were also informed about such alerts through emails and during handover.

Safety thermometer The service used safety monitoring results well. The Safety Thermometer is used to record the prevalence of patient harms and to provide immediate information and analysis for frontline teams to monitor their performance in delivering harm free care. Measurement at the frontline is intended to focus attention on patient harms and their elimination. We checked safety thermometer results from December 2017 to December 2018. We found that results fluctuated each month. For example, in April 2018 only 80% of patients received harm free care and in November 2018 this figure improved to 100% of patients. In December 2018 results dipped again to 95.2%. However, we saw improvement in safety thermometer results overall. We also found that the majority of patient harms reported were for pressure ulcers and appropriate action was being taken to reduced incidences of pressure ulcers.

Is the service effective? Evidence-based care and treatment The service provided care and treatment based on national guidance and evidence of its effectiveness. We saw that relevant and current evidence-based guidance, standards, best practice and legislation were discussed at the services monthly quality, performance, risk and governance meetings. We reviewed the electronic healthcare records (EHR) of nine patients. All patients had their needs assessed and their care planned and delivered in line with evidence based, guidance, standards and best practice. For example, we found that patients receiving intravenous (IV) fluid therapy were cared for by staff who were competent in assessing patient’s fluid and electrolyte needs, prescribing and administering IV fluid, and monitoring patient experience. This was in line with the National Institute of Health and Clinical Excellence, Quality Statement 2 (2014). The service participated in local and national benchmarking. Local benchmarking occurred through participation in the “East of England Critical Care Network”. The CCC clinical lead represented the Norfolk and Norwich University Hospital critical care service. Records we checked showed they attended regular network meetings, contributed to these meetings and shared necessary information with their staff locally. The service also contributed and uploaded data regularly to the Intensive Care National Audit Research Centre (ICNARC), which provides information/feedback about the quality of care to

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 203 those who work in critical care to allow service benchmarking against similar critical care units nationally. There were no audits conducted which related to patient’s mental health and emotional wellbeing. A manager confirmed this. The critical care unit used care bundles. A care bundle is a group of evidence-based interventions, when performed together; improve outcomes more than if used individually. We saw that ventilator care and surviving sepsis care bundles were in use. We checked 12 policies and procedures relevant to the service and found that all were up-to-date, accessible to staff and reflected evidence-based-practice. We discussed the Mental Health Act (1983) with managers. They demonstrated they understood the MHA Code of Practice sufficiently and that the rights of any patient subject to the MHA would be protected. Staff told us that they did not use the Lester tool or a similar resource to monitor the physical health of people with severe mental illness. A manager confirmed this finding. Such resources assess cardiac and metabolic health in patients with serious mental health conditions.

Nutrition and hydration Staff gave patients enough food and drink to meet their needs and improve their health. We checked nine patient’s electronic healthcare records (EHR). All patients had their fluid balance and nutrition assessed hourly, with a recent malnutrition national screening tool (MUST) score and up-to-date nutrition and hydration care plan was in place. The records also showed that each patient had regular input from a dietician. There was a whole time equivalent (WTE) designated dietician assigned to the CCC service who was available Monday to Friday. Managers told us that a business case had been written and was awaiting approval to increase dietetic staff by 0.86 WTE hours. We saw that patients who were unable to take food and fluid orally had nutrition support (enteral or parental) commenced on admission. This ensured adequate nutrition to facilitate rehabilitation. We also saw that the dietician was involved in the assessment, implementation and management of appropriate nutrition support. Staff told us that there was a referral policy to the dietetic service and an out of hours (OOH) procedure for enteral feeding support, which they followed. We saw that there were regular meals, drinks and snacks provided for patients who could eat and drink. Visitors were also offered hot and cold drinks.

Pain relief Staff assessed and monitored patients regularly to see if they were in pain. All five patients we asked told us that their pain was well controlled and that staff checked their pain levels frequently. Staff used a standardised tool to assess patient’s pain.

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We checked the electronic healthcare records (EHR) of nine patients and found that their pain assessments were checked regularly. There were pain scoring charts in each record with individualised pain relief plans in place, which were appropriate to each patient’s clinical condition. Staff were aware of the hospital’s acute pain service team. They gave us examples of when the team had supported critical care patients. We saw that a consultant liaised with the acute pain team for support with a patient who had a history of substance misuse because their pain management was difficult. The pain team were quick to respond. There was a “communications trolley” containing varying communication tools. These tools assisted staff when assessing the pain of a patient who had difficulties communicating. For example, there was a picture pain scale for children. Staff told us that they found these resources very useful.

Patient outcomes Managers monitored the effectiveness of care and treatment and used the findings to improve them. Audit calendars were in use and were regularly updated and acted upon. The calendar showed the planned audits for the service for 2018/2019. The local audit programme included clinical documentation, medicine management, safeguarding, premises and equipment, consent and person-centred care and dignity and respect audits. We checked the results of three of these local audits. The results showed good compliance with standards set, which were in line with relevant evidence based practice. For example, the audit results for monthly commode cleanliness from December 2017 to December 2018 identified 100% compliance with set cleaning standards. There were numerous medical-led audits which included, “Recording invasive procedures in critical care complex”, “Audit of out of hospital cardiac arrest targeted temperature management” and daily patient venous thrombosis (blood clot) checks. There was also a “LocSSIP’s Documentation Audit and Re-Audit for Central Venous Catheters (CVC) and Nasogastric tubes (NGT) in Critical Care Complex (CCC)” audit. LocSIPP’s is an abbreviation for the term local safety standards for invasive procedures. We checked the LocSSIP’s audit results from July and October 2018. The audit used 20 samples and was carried out over two months and divided into a first and second audit. Results showed significant improvement between the first and second audit. In July CVC placement LocSSIP’s standard was met in 67% cases and in October this increased to 100%. The NGT LocSSIP’s standard was met in 30% cases in July and 67% in October. There was an action plan developed following the audit analysis which included ensuring LocSIPP’s sticker availability in all areas of CCC, orientation of new staff to documentation, LocSSIP’s procedures in patient’s EHR and educating staff about the importance of using LocSSIP’s. We found that all these actions had been achieved. The CCC service contributed to the Intensive Care National Audit Research Centre (ICNARC), which meant that the outcomes of care delivered and patient mortality could be benchmarked against similar units nationwide. ICNARC data showed that the CCC’s risk adjusted hospital mortality ratio was 1.0 in 2016/17. The figure in the 2015/16 annual report was 0.9. These figures were within the expected range. 20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 205

Number of Metric 2015/16 2016/17 National Asp Comparison cases aggregate Standard

Risk-adjusted 1,694 hospital 0.9 1.0 1.0 none Within expected range admissions mortality ratio (all patients)

The risk adjusted hospital mortality ratio for patients with a predicted risk of death of less than 20% was 1.0. The figure in the 2015/16 annual report was 0.8. These results were within expected limits. Number of Metric 2015/16 2016/17 National Asp Comparison cases aggregate Standard

Risk-adjusted hospital mortality ratio 1,302 for patients 0.8 1.0 1.0 none Within expected limits admissions with predicted risk of death <20% (lower risk)

The most recent ICNARC report from 01 April to 30 September 2018 showed patient outcomes continued to be good. During this reporting period there had been 962 CCC admissions. The risk- adjusted hospital mortality ratio (all patients) was 1.04; the risk-adjusted hospital mortality ratio for patients with predicted risk of death <20% (lower risk) was 0.91; 2.5% of patients were discharge out of hours but not delayed; unplanned readmission rates were 1.2% and there were no non- clinical transfers to other units. All these quality indicator (QI) outcomes were within the range expected. The service was part of a local Critical Care Operational Delivery Network (CCODN). Every two years this CCODN conducted a peer review of the CCC which was a quality assurance process. We checked the latest peer review report dated November 2017. The report showed that there had been improvements made since the prior review in 2015. That the majority of concerns had been addressed, however, it also identified that there were some areas that still needed improving. This included the need to introduce a system to record whether patients were discharged from the CCC within four hours following decision to discharge. It was also identified that the outreach team did not operate a 24/7 service with hand over after 8:30pm to the hospital at night team. Whilst the report stated that the handover process worked well it recognised that the hospital at night team service was different to outreach in general as it, “tends to focus on the oversight of patients and escalation”. It also mentioned that 83% of CCOT services within the network operated a 24/7 outreach service so therefore the service was an “outlier”. Review of audit took place every month during the services “quality, performance, risk and governance meetings”. We checked the last three minutes for the meetings held in October and December 2018 and January 2019. We found that these meetings were well attended, there was a set agenda including a section dedicated to audit and research. There was evidence that changes to practice had been made following audit. Two audits were carried out in June and August 2018 to determine whether patient’s daily VTE assessments had

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 206 been carried out and recorded in their EHR. There were 85 patient records checked over five days. Compared results between June (51% compliance) and August (68% compliance) showed improvement. There were also plans to repeat this audit in 2019. Following audit, we saw that dissemination of information to staff had happened and notices were displayed throughout the CCC reminding staff to do VTE assessments. We saw that VTE assessments had been recorded in all the nine patient records we checked. The service had a research team consisting of two registered nurses which equated to one WTE. They were supported by the hospital research team. The local research team led the critical care service’s involvement into a number of national clinical trials relevant to critical care services. This included the ICNARC6 trial. ICNARC65 related to evaluating the clinical and cost-effectiveness of permissive hypotension in critically ill patients aged 65 years or over with vasodilatory hypotension. The trust had funded the CCC’s lead research nurse to complete the training module titled, “The Essentials of Research” at a local university due to start 2019. This was to support their research role.

Competent staff The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service. Records showed that 81.6% of nursing staff and 100% of medical staff had received an appraisal in the past 12 months. This was against a trust target of 90%. Staff told us that learning needs were identified during appraisals and they were supported to develop their knowledge and skills. Staff did not receive one-to-one meetings with their manager. However, staff told us that leaders of the service were always available for support. This included supporting revalidation processes. A manager explained how poor or variable staff performance was identified and managed. They gave us a past example where this had happened and how the member of staff was supported to improve in the first instance. The service employed newly qualified registered nurses. We saw a comprehensive induction programme in place for new starters and were told they received a period of approximately four to six weeks supernumerary practice initially. This included the allocation of a mentor who worked alongside them, an induction checklist and role specific competencies. These competencies were to be completed within the first year in post. Staff confirmed that new starters were well supported. Staff had received appropriate training relevant to their role. We were shown staff competency packs for new starters which were completed and all nursing staff completed the national “Step Competency Framework” for critical care nurses (step one to three). A manager confirmed that the step four competencies from this framework were going to be introduced in late 2019. Step four was for staff that were planning to take on a more senior role including taking charge of the unit. Student nurses completed placements on the CCC. Students allocated were in their final year of study. Records showed there were 57 registered nurses who had completed mentorship training which equated to more than 50% of nursing staff. Staff confirmed there was also a suitable number of sign off mentors to support students. A manager told us that all of the ten consultants in post had intensive care accreditation.

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Only 46% of registered nurses had completed their post registration award in critical care nursing. This meant that the service was not meeting national guidelines which state that 50% of registered nurses working in intensive care should have completed this qualification (Guidelines for the Provision of Intensive Care Service, 2015). However, a manager told us that this was due to staff leaving and that a further six nurses were in the process of completing this training and following this the service would meet the standard. We were also told that there were further training places secured for 2020 and staff had been encouraged to apply. Pharmacy staff were only permitted to working in critical care if they had received specific training and were considered competent. Pharmacy staff told us that they were well supported by the pharmacy lead for critical care and the trust senior pharmacy team. Staff across the service repeatedly told us that additional training opportunities were excellent and that they were able to attend any training they needed. Records showed that regular study days were available for staff. We saw a “CCC Education Programme” dated 2019 which outlined educational dates set for the year ahead. Each month there were between four and six dedicated training days. Topics covered included simulation, paediatric care, spinal awareness, transfer, organ donation and tracheostomy training. Doctors told us they had twice weekly training sessions which they were always able to attend. One doctor told us, “We are supported to develop” and another told us that, “Training opportunities are brilliant here”. There was a large simulation room located on Gissing HDU, which was used for staff training including simulation practice. The room included a state of the art manikin, hospital bed and the ability to film simulation practice. One of the CCC medical trainees led simulation training and was allocated to this dedicated role two days per week. Nursing staff did not complete competencies for children and young people’s care. This was despite children and young people regularly being admitted to the CCC. A manager confirmed this finding. However, there was an allocated nursing lead for children and young people within the CCC who was a senior nurse (band 7). Records also showed that four registered nurses were allocated to spend a week shadowing PICU staff at a nearby trust commencing 04 March 2019. A manager explained to us that during this shadow period these staff would be completing competencies, with the view that only these four staff would be caring for children and young people in the CCC after this. Training records showed that there were two CCC paediatric study days planned for May and September 2019 which all staff were invited to attend.

Multidisciplinary working Staff of different kinds worked together as a team to benefit patients. We observed a good rapport between all staff groups across the service. We found that all necessary staff, including those in different teams and services, were involved in assessing, planning and delivering patient’s care and treatment. We saw that daily multidisciplinary team (MDT) ward rounds took place for all patients admitted to the CCC. MDT meetings also took place daily and included consultants, speech and language therapists (SALT), physiotherapy, microbiology and lead nursing staff.

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Staff repeatedly told us that the entire MDT works well together. One member of staff told us, “Everyone works well together here, it doesn’t matter what your role is we all have the same high standards”, and another said, “We are a great team and everyone is so supportive”. Bi-monthly staff forum meetings were held which all members of the MDT were invited to attend. We reviewed the minutes of these minutes from October to December 2018 which showed a set agenda and that meetings were well attended by the MDT. We checked the EHRs of six people who used the service during our inspection. We found that on admission all patients had a treatment plan discussed with a consultant intensivist. We tracked one patient who had been transferred and stepped down from the CCC to a medical ward. We saw a clear discharge and handover protocol in place which was followed by medical and nursing staff. This included a robust CCC discharge print out which went with the patient to the ward. There was also evidence of an MDT approach to discharge. There was a dedicated speech and language therapist (SALT) for the service. They worked five days a week aiming to meet the service standard of identifying all new patients within 24 hours of admission. There was a dedicated physiotherapy team for the service consisting of two senior physiotherapists (band seven), one band six, four band five physiotherapists on rotation and three physiotherapy assistants. Physiotherapists told us that they performed a short clinical assessment on all patients as early as possible, to determine the patient's risk of developing physical and non-physical morbidity. We saw this happen and documented in patient records. There were established links between the service and mental health, learning disability, autism and dementia services. For example, there were specialist teams within the trust for learning disability, mental health and dementia. Staff could give us examples of when these specialist teams had provided support to critical care patients. We also saw this happen during our inspection.

Seven-day services There was a critical care consultant present during daytimes hours, seven days a week. Out of hours, usually after 06:00pm, there was a critical care consultant on call for the critical care service, who was able to attend within 30 minutes. Consultant-led ward rounds took place twice daily for all patients admitted to the CCC. When patients were stepped-down from the CCC to ward areas, care was taken over by the speciality team, such as surgery or care of elderly team. However, the critical care team including a consultant were available at all times for advice and support. We checked five patients’ electronic healthcare records (EHRs) and saw that all emergency admissions were seen and had a clinical assessment by a critical care consultant promptly. There was a pharmacy team allocated to the CCC on a basic contract providing 2.5 hours per weekday. The team consisted of a lead pharmacist, and two junior pharmacists one of which was on rotation. At weekends the trust-wide OOHs pharmacy team were available which included a senior pharmacist with critical care experience. A business case had recently been approved to increase the pharmacy service to a seven day a week service with an aim to recruit fully by April 2019.

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Specialist dietetic support was available daily Monday to Friday. Outside of these hours staff completed an initial dietetic assessment and followed the OOHs protocol, for patients requiring enteral (tube) feeding. There was a microbiologist allocated to the service who participated in daily MDT meetings. OOHs an on call microbiologist was available at all times. Staff told us that the hospital’s mental health liaison service was available for advice and support 24 hours a day, seven days a week. Doctors confirmed there was seven-day access to diagnostic services such as x-ray and computerised tomography (CT). This included consultant-directed diagnostic tests with results available within one hour.

Health promotion Staff across the MDT ensured health promotion was embedded into patient care from admission and beyond discharge. Health promotion is the process of enabling people to increase control over, and to improve, their health (World Health Organisation, 2018). The physiotherapy team used “The Chelsea Critical Care Physical Assessment Tool (CPAx)” for adult patients to measure physical morbidity. The CPAx is a measurement tool used to assess physical function in critical care in view of planning for early rehabilitation. We saw these tools being used and performed weekly for level three patients. We saw that patients had completed short risk assessments for rehabilitation in their healthcare records, which had been completed soon after admission. These risk assessments should be completed during all patients’ critical care stay, and as early as possible to determine the patient’s risk of developing physical and non-physical morbidity (National Institute of Health and Clinical Excellence, Clinical Guideline 83: Rehabilitation after critical illness, 2009).

Consent, Mental Capacity Act and Deprivation of Liberty Safeguards Staff understood how and when to assess whether a patient had the capacity to make decisions about their care. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. Staff demonstrated sufficient understanding about consent, the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). They told us what action was taken when a patient lacked mental capacity and demonstrated that care provided was in line with hospital policy and procedure. We reviewed the electronic healthcare records (EHR) of seven patients admitted to the CCC during our inspection. All patients had their mental capacity assessed daily since admission. The assessments were embedded into the EHR system and were mandatory entries. There were trust policies in place for consent, MCA, DoLS and restraint. We reviewed three policies relating to these subjects and found they were up-to-date and where necessary reflective of legislation such as the Mental Health Act (1983). The trust set a target of 90% for completion of MCA and DoLS training. A breakdown of compliance with this training at September 2018 for qualified nursing staff in the CCC is shown below:

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Number of staff Number of trained eligible Completion Trust Met Name of course (YTD) staff (YTD) rate Target (Yes/No) Mental Capacity Act Level 1 115 124 92.7% 90% Yes Deprivation of Liberty Safeguards 115 124 92.7% 90% Yes

Qualified nursing staff met the trust training target for both training modules relating to the Mental Capacity Act (MCA) and Deprivation of Liberty (DoLS). Records we saw after our inspection showed that 91.6% of medical staff were up-to-date with MCA and DoLS training requirements. Staff were able to demonstrate that consent and decision-making requirements for children were made in accordance with relevant legislation. They were also aware of and able to access the trust’s policy and procedure in relation to this.

Is the service caring? Compassionate care Staff cared for patients with compassion. Nine patients and relatives during our inspection told us that staff were incredibly caring and kind. One patient told us they felt really well looked after and felt safe. A relative told us they were, “Very happy with care”. The Friends and Family Test (FFT) was used by the service. The FFT consists of patient feedback forms to determine how likely people are to recommend the service to friends or family. From December 2017 to November 2018 the average FFT results were 90. However, there were four months during this reporting period with no result. This meant that there was regular missed opportunity to attain service feedback. We consistently observed staff act in a kind and sensitive manner towards patients and those close to them. For example, one relative was upset of a very unwell patient had lost their phone. They said they were not thinking clearly due to the circumstance. We saw staff try to help the relative find their phone by calling it and searching through laundry. This relative knew their patient’s nurse on first name basis and told us, “The nurses really are so lovely and kind here”. Staff understood and respected people’s personal, cultural, social and religious needs. Such needs were taken into account during the planning and delivery of care. We saw this in patient’s initial assessments where these aspects of their life had been assessed. One level three patient’s religion was Church of England and we found that, with their family’s agreement, the Chaplain had been to visit them. Patient’s privacy and dignity was respected. We saw staff closing curtains around bed spaces and closed doors to side rooms, when personal care or clinical review took place. We also heard staff keeping their voices low during ward rounds so as patient’s auditory privacy was maintained reasonably. Staff were seen introducing themselves to all patients and explaining what they were doing, including when patients were sedated. There was information throughout the service which showed the roles and responsibilities of different members of the team. For example, outside the entrance to the CCC there was a notice showing the uniforms different members of staff wore. 20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 211

Staff acted in a timely and compassionate way when patients experienced physical pain and discomfort. For example, we saw one patient who was intubated and sedated showing signs of distress. The nurse caring for this patient recognised this immediately and increased the sedation, in line with the patients care plan. The nurse also explained to the patient what they were doing through the process. There were thank you cards to staff from patients and relatives displayed in abundance within the service. The dates on the cards showed that they were received recent to the time of inspection.

Emotional support Staff provided emotional support to patients to minimise their distress. There were dedicated areas within the service which could be used to deliver bad news to patients and their relatives. For example, the waiting room in the main unit had a sectioned off area with a door and comfortable seating. We saw one patient become distressed in an open-bedded area. The staff team responded to them immediately and the cubicle curtains were drawn to ensure the patient’s privacy and dignity was maintained. A hospital chaplaincy service was available 24 hours per day, seven days per week. The chaplaincy team offered, “Compassionate care and spiritual support to all”. We saw notices displayed throughout the CCC informing patients and those close to them about this service. Patient diaries were offered for all level three patients who had been admitted to the CCC for more than three days. Patient diaries provide a daily record of each day’s event intensive care admission. We saw numerous patient diaries in use and notices promoting the use of the diaries. Two CCC nurses offered a bereavement service for bereaved families. Following the death of a loved one, all bereaved families were provided with a hand-written card in hospital explaining the bereavement service. This was followed by a personalised appointment letter offering further support between eight to 12 weeks later. Staff told us that the team could arrange meetings with the consultant for debrief of events leading to the death. The team also signposted the family to other services for additional support as required.

Understanding and involvement of patients and those close to them Staff involved patients and those close to them in decisions about their care and treatment. All nine patients and relatives we spoke with all told us that staff communicated well with them, and they understood care, treatment and condition. Four specialist nurses for organ donation (SNODs) were based in the main CCC. They worked throughout the hospital including critical care. Staff told us that consultants explained to relatives and loved ones of patients why treatment was stopping, however, that the SNODs then came in to discuss organ donation as required. This had reportedly led to a higher organ donation acceptance rate. Records showed there were regular organ donation study days available to staff. The next one was planned for July 2019. There were also leaflets about organ donation available to patients and visitors.

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There was a communications trolley within the CCC consisting of numerous communication aids. This included pens, paper, whiteboards, communication charts with pictures and a handheld electrical tablet which had child-friendly features. This helped patients become partners in their care and treatment. Advocacy and support service details were displayed on notices and visible for patients and those close to them.

Is the service responsive? Service delivery to meet the needs of local people The trust planned and provided services in a way that met the needs of local people. The CCC was a purpose built modern critical care facility consisting of 28 adult critical care beds over two locations within the hospital, providing level two (high dependency) and level three (intensive care) services. The main CCC unit had 20 beds, consisting of ten level two and ten level three beds. Gissing High Dependency Unit (GHDU), which was a short walking distance away from the main CCC, had eight level two beds. Children of any age, providing they weighed more than 5kg, were admitted to the CCC in an emergency whilst being stabilised and awaiting transfer out to a paediatric intensive care unit (PICU) facility. Children between the ages of 12 and 16 were also admitted to the CCC post elective surgery. That was if they required enhanced care beyond the provision of the hospital’s dedicated children’s HDU (Buxton ward). No formal needs assessment had been conducted to support the planning of the CCC service provision. However, we saw some examples showing that the service was planned to meet the needs of the people it served. For example, the Gissing HDU had been built 2008 as an expansion for the CCC due to an increase in admissions. Outside the main unit there was a large waiting area for visitors. The area contained many chairs, a television, a sectioned off area with screens for privacy and a small relatives’ room. In the relatives’ room there were two chairs that reclined into beds to allow those close to patients to stay overnight. However, compared to the size of the service we found that the overnight facilities did not equate to what was needed. Staff we spoke with also told us that they felt these facilities were not sufficient. Visiting hours were between 2pm and 8pm, seven days a week. However, staff told us that the hours were flexible dependent on people’s needs, or if a patient was very unwell then visiting hours would be open. There was a vending machine with food and drink for sale within the waiting area. We saw that staff also offered visitors hot and cold drinks. Physiotherapists told us that patients had access to a regional home ventilation and weaning unit as required. We found it difficult to locate the CCC as signage throughout the hospital was not clear. Relatives we spoke with also raised this concern.

Meeting people’s individual needs The service took account of patients’ individual needs.

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There were translation services available which could be booked through the hospital switchboard. Staff told us that arranging translation services was easy and gave examples where the service was used. Patients who were able to eat and drink could choose their meals from a selection of menus. These included vegan, gluten-free, kosher and halal choices. We saw that different textured food was also available. Staff told us that they could access a range of patient leaflets in easy read, large print and in different languages as required. This was via the trust intranet system. Staff had access to a number of specialist teams within the trust for patients who needed additional support. This included for example, the frailty team who could provide additional support and advice for patients who were frail and elderly. There were a range of aids available which staff could use to support patients living with a sensory loss, such as hearing loss, dementia or delirium. We saw the, “This is me” dementia scheme in use for patients living with dementia. This is me is a simple form for anyone receiving professional care who is living with dementia or is experiencing delirium or other communication difficulties. All level three patients who had been admitted to the CCC for more than four days and discharged were offered a follow up clinic appointment at three months. This service was led by a CCC nurse and delivered by a MDT as required. Patient’s electronic healthcare records (EHR) showed that patients experienced care that was tailored to their needs and personal preferences, taking into account their circumstances, their ability to access services and their coexisting conditions. For example, patient admitted during our inspection lived with a learning disability and we saw that the learning disability team had been referred to for additional and tailored support. Another patient had a young son aged four and we saw that staff temporarily moved this patient to Gissing HDU so as the son could visit his father in a more suitable environment. Appropriate discharge arrangements were planned for people with complex health and social care needs. Staff told us they planned discharge arrangements with external service such as community mental health teams (CMHTs), community learning disabilities teams (CLDTs) and child and adolescent mental health teams (CAMHS) where required. The service held additional MDT meetings for patients with complex needs, who had been admitted for between 10 to 14 days. This was to ensure that care was holistic and tailored to individual need as much as possible. Staff told us that where possible patients were cared for in separate male and female areas. Same sex breaches were monitored monthly. From December 2017 to December 2018 there had been six same sex breaches. The trust target was zero and this was met in eight of these 13 months.

Access and flow In an emergency people could access the service when they needed it. However, cancelled elective admission rates were high. From October 2017 to September 2018, Norfolk and Norwich University Hospitals NHS Foundation Trust had seen adult bed occupancy range from 65.4% (May 2018) to 92.0% (April 2018). In September 2018, CCC bed occupancy was 80.0%, which was the same as the England average for September 2018.

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Adult critical care Bed occupancy rates, Norfolk and Norwich University Hospitals NHS Foundation Trust.

Data from 2015 to 2017 below shows delayed discharge rates for this period. Of 6,935 available bed days, the percentage of bed days occupied by patients with discharge delayed more than 8 hours was 1.2%. This compares to the national aggregate of 4.9%. This meant that the unit was not in the worst 5% of units. The figure in the 2015/16 annual report was 6.5%. Number of Metric 2015/16 2016/17 National Asp Comparison cases aggregate Standard

Crude delayed discharge (% 6,935 bed-days available Not in the worst 5% of occupied by 6.5% 1.2% 4.9% 0% critical care units patients with bed days discharge delayed >8 hours)

Between 2016 to 2017 there were 1,791 admissions to the CCC, of which 0.1% had a non-clinical transfer out of the unit. This was within expected range. The figure in the 2015/16 annual report was 0.3%. Number of Metric 2015/16 2016/17 National Asp Comparison cases aggregate Standard

Crude non- 1,791 clinical 0.3% 0.1% 0.4% 0% Within expected range admissions transfers

1.2% of the 1,791 admissions were non-delayed, out-of-hours discharges to the ward. These are discharges which took place between 10:00pm and 6:59am. This was within expected range. The figure in the 2015/16 annual report was 0.8%. Number of Metric 2015/16 2016/17 National Asp Comparison cases aggregate Standard

1,460 Crude, non- 0.8% 1.2% 1.9% 0% Within expected range admissions delayed, out- of-hours

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discharge to ward proportion

The quarterly ICNARC report from 01 April to 30 September 2018 showed that during this period there had been 962 admissions to the CCC. Results showed 2.1% of patients experienced more than an eight hour delay and 0.9% of patients more than a 24 hours delay, after the time they were fully ready for discharge. These values were within the expected range and below the values of other similar units. A standard operating procedure (SOP) was in place for, “The management of bed capacity issues within the CCC”. This document was dated October 2016 with a three year review date. It showed that an additional level two beds could be provided in the recovery area of main theatres if CCC capacity was reached. Staff told us the SOP was followed as required. Elective bed bookings were managed by the clinical coordinator daily. The issue was discussed every morning during the services “safety huddle” meetings. Patients were admitted to the ward areas and taken to theatres when the CCC confirmed their allocated bed space. We saw the matron for the service attended regular trust operation meetings, where ward step- downs were prioritised. Technology was used to support timely access to care and treatment. An electronic healthcare records (EHR) system was in place which was critical care specific. The entire MDT used the system. There was a consultant lead for the EHR system that completed modifications when asked. This meant the system was consistently being adapted to improve care and treatment. We also saw that telephone systems and digital services were available to staff and easy to use.

Learning from complaints and concerns The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff. From October 2017 to October 2018 there were five complaints about the service. The trust took an average of 31 days to investigate and close complaints, and 60.0% of the complaints were closed within 25 days. This is in line with their complaints policy, which states that more than 50% of complaints should be closed within 25 days. A table of complaint subjects can be found below. Number of Percentage of Core service complaints total complaints Clinical Treatment - Anaesthetics 2 40.0% End of Life Care 1 20.0% Prescribing Errors 1 20.0% Other 1 20.0% Total 5 100.0%

In relation to these five complaints a breakdown by area can be found below.

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Percentage of Number of Ward name/area total compliments compliments High Dependency Unit 4 80.0% Gissing HDU 1 20.0% Total 5 100.0%

We checked the trust responses for the last three complaints. We found that complaints were investigated appropriately, handled effectively and were responded to in a timely way. None of the five complaints had been raised to the Parliamentary Health Service Ombudsmen (PHSO). Lessons were learnt from concerns and complaints and action was taken as a result to improve the quality of care. One complaint was from the parents of a child who had used the service. They raised concern they had heard different consultants disputing treatment plans for their child. We found that the clinical lead met with the family promptly after the complaint, and subsequently consultants now discussed disagreements discreetly away from patients and relatives. Learning from this complaint had been disseminated to all staff including via the bi-monthly staff forum meetings. There were notices displayed throughout the service informing people how to make a complaint or raise concerns. This included details of the trust’s Patient Advice and Liaison Service (PALS) and the PHSO.

Is the service well-led? Leadership Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care. The critical care service was part of the hospital’s surgical division, which was headed by a clinical nurse director and senior matron. A clear management structure existed for the critical care service. This included a designated clinical lead who was an accredited critical care consultant, a lead nurse who was a matron (Band 8a), with overall responsibility for the nursing elements of the service and a general manager. The matron had only been in post a couple of weeks at the time of our inspection. There was an allocated lead consultant and clinical coordinator (charge nurse band 7) on duty 24 hours a day, seven days a week. There were also a charge nurse in each of the three areas of the CCC. Notices were displayed throughout the service stating who the leads for the service were. For example, there was a notice board at the entrance of the main CCC unit showing the names of the consultant, charge nurse and coordinator for the area that day. Staff across all levels consistently told us that managers were supportive, visible and approachable. They spoke incredibly highly of the clinical lead. It was clear from speaking to staff that there had been a lack of strong nursing leadership previously. Stall told us they were excited about the appointment of a new matron for the service. One member of staff told us, “I am very impressed with them already, we need better nursing leadership”. Another member of staff told us, “It will be great having a new matron – we need strong nursing leadership to maintain our standards, some things have drifted”.

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We saw service leads encourage appreciative supportive relationships among staff. Staff told us that the culture of the service was good. Leaders demonstrated they had the skills, experience and integrity to lead the service. The clinical and nursing leads for the service were responsible for the critical care service alone. They were supported by a general manager who was responsible for business elements of the service. We observed a good rapport between the three service leads. They demonstrated they worked exceptionally well together, challenged one another where needed and strived unanimously for high quality patient care.

Vision and strategy The trust had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups representing the local community. Staff were familiar with the trust’s set of values, with quality and sustainability as a top priority. We saw the trust’s vision and values displayed throughout the service. The CCC was in the process of developing its own set values. There was information for staff in a newsletter dated January 2019 asking them for ideas about values. We also saw a box in the staff room where these ideas could be posted. There was no formalised vision and strategy for the CCC. However, we did find that leaders had set aims and service priorities which were being achieved. Aims and service priorities were recorded in quality, performance, risk and governance meetings and on the service risk register, with evidence of monitoring and review of aims. The service’s broad vision and strategy was aligned to local plans in the wider health and social care economy, to meet the needs of the local population. For example, the CCC was part of The East of England Critical Care Operational Delivery Network This network consisted of 18 critical care services and other stakeholders. The aim of the network was to improve access, experience and outcomes for patients using the critical care services. Records showed the service worked regularly with this local operational delivery network. For example, staff from the CCC attended a “transfer study day” which was available periodically and delivered in partnership with the network.

Culture Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. In the 18 months prior to our inspection CQC received whistle-blowing information from five members of staff raising concern about culture of the CCC. During our inspection managers told us that culture had in the past been an issue, particularly among nursing staff. However, since certain changes had been made, including new leaders being appointed, they told us that the culture concerns had improved significantly. Staff we spoke with across all levels confirmed this.

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Staff repeatedly told us that they felt valued and respected by one another and leaders. They also explained they enjoyed working for the service. One member of staff told us that the CCC was a, “Brilliant team, I feel very supported”, another told us they were, “Very proud of the team and to be working in the hospital”. Due to the previous cultural concerns managers had invested in a culture-specific staff survey to identify specific areas of concern. At the time of our inspection this survey had almost been completed. One manager told us that there were still improvements to be made around culture. This was in relation to the cohesiveness between the three areas of the CCC. The manager told us that they worked independently from one another. The leadership team demonstrated they were exploring this issue. Staff were open and honest to us about what worked well in the service and where improvements were required. Data provision from the service was prompt when we requested this and data reflected what we were told. Managers told us that action was taken where required to address behaviour and performance that was inconsistent with the trust vision and values. This was regardless of seniority. They gave a recent example whereby an incident was raised due to a member of staff not adhering to policy and procedure. We found that appropriate action had been taken. There were notices throughout the service which reminded staff about the trust’s “Freedom to Speak Up (FTSU) Guardians. This was a group of six members of staff who were available to support staff to raise concerns freely. Staff told us that they were encouraged to report incidents. They felt able to raise concerns without fear of retribution and demonstrated that action was taken by managers as a result of concerns raised. During our inspection the hospital was extremely busy which impacted on CCC capacity. We saw that patients were still waiting to be stepped-down to ward areas whilst admissions were coming in. However, appropriate action was seen to be taken by CCC staff. The charge nurse raised concern to management as they were required to care for patients when they were meant to supernumerary. As a result of this, managers including the matron supported these members of staff, by working clinically for a period of time to free up the charge nurse. There was strong emphasis on the safety and well-being of staff. Staff told us that there were staff running groups and regular activities arranged for the team. We also saw future planned social events displayed on the staff room notice board. Doctors told us about a team of senior medical staff called the “fatigue team” who supported them in reducing fatigue levels due to work. Doctors told us that this team had helped them improve their staff rooms, including putting in place black out blinds and do not enter notices on doors when doctors were resting when on call. Doctors also told us that they were encouraged to take their break by consultants and had to report when this did not happen.

Governance The trust used a systematic approach to continually improving the quality of its services and safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish.

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A clear governance framework was in place to support the delivery of good quality care. Governance of the service was led by the clinical lead, matron and general manager. There were monthly quality, performance, risk and governance meetings which were for the clinical management group one month and then for all staff the following. We checked the minutes from these meetings between November 2018 and January 2019. These showed there was a set agenda and that meetings were well attended. However, we also found that the agenda for these meetings was very long with no record of discussion under some agenda headings. The action plan at the end of each set of minutes had also not been completed and signed off. A manager explained that the bi-monthly quality, performance, risk and governance meetings (staff forum) had been planned to coincide with mandatory training days to improve nursing staff attendance at meetings. Since the introduction of these meetings per this set up, nursing attendance had quadrupled. All staff we spoke with were clear about their roles and understood what they were accountable for. Leaders were able to explain the leadership structure for the service and understood what each leader was responsible for. There were arrangements in place for the monitoring and management of service level agreements (SLAs). This included but was not limited to the cleaning and maintenance of equipment. Records showed that the service responded to concerns raised by third parties such as equipment coming to the end of its working life. We found overall that the governance framework arrangements allowed for a holistic understanding of service performance, which integrated the views of people who used the service with safety, quality, activity and financial information. There were assurance processes in place to ensure that data collection was reliable and accurate. There was a dedicated team for data upload to ICNARC with plans in place to expand the team. There was also a dedicated CCC research team who led the service’s involvement in national clinical trials.

Management of risk, issues and performance The trust had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. There were systems and processes in place to ensure that risk, issues and performance were regularly reported on, monitored and managed effectively. This included a service risk register, a performance dashboard and incident and complaints logs. We reviewed the risk register for the CCC and found that this was up-to-date, with staff allocated and accountable to different risks. However, we found that not all known risk was recorded. This included regarding the absence of a clinical nurse coordinator out of hours and nursing staffing vacancies. When we returned unannounced on 6 February 2019 we did however find that these known risks where being added to the risk register. The NHS safety thermometer was used and reviewed regularly with results showing improvement overtime. The service operated a local and national audit programme which fed into service improvement. A performance dashboard was in place called the, “CCC Nursing Dashboard. This was red, amber, and green (RAG) rated to easily identify risk, with performance measures set. The

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 220 dashboard gave oversight of the past years performance and included infection control, incidents, medicine management, pressure ulcer, falls, staffing numbers, staff training compliance and local nursing audit outcomes. However, the dashboard did not reflect the responsiveness of the service including out of hours discharge rates, admission rates, readmission rates and standard mortality rates, which may have assisted with service oversight as not all managers knew or could access this information when asked. Meetings called “safety huddles” had recently been introduced by the service which took place every day during medical handover. These were attended by consultants, doctors, the clinical coordinator and matron. Hospital-wide operations meetings took place every two hours between Monday and Friday, which the matron for the day attended. Each matron in the surgical division was matron of the day one day per week. Every morning between Monday and Friday there was also matron meeting at 08:45am which the CCC matron attended. These meetings were opportunities to discuss workforce and bed capacity and action plans were made accordingly. Records showed there was paediatric critical care meetings held four times year. These were attended by leads from the CCC and leads from the children and young people’s core service.

Information management The trust collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards. An electronic patient board was on the main CCC unit which contained sufficient yet non-patient identifiable information about patient’s needs. Patient initials and symbols were used to inform staff of people’s particular needs. For example, if the patient was being nursed in isolation due to infection risk a particular symbol was displayed. We saw that authorised staff had access to trust-wide systems for patient’s blood and radiology results. Staff confirmed that patient’s past medical records could be requested and accessed by the service at all times. Staff told us they could access their work email account where they accessed information updates from managers. They also showed us they could access the staff intranet system which contained links to policies, guidelines and general trust wide information. We found that information technology systems were used effectively to monitor and improve the quality of care. This included the electronic patient records system which was specific for critical care services. Staff told us they had received training on data protection and were aware of the associated legalities.

Engagement The trust engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively. Patients and those close to them were encouraged to give feedback about their views and experience of the service. This included via the Friends and Family Test (FFT) and the service’s

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 221 compliments and complaints system. However, staff confirmed there was no children and young person specific feedback system in place. There were notices throughout the service which informed patients and those close to them how to raise comments and concerns. This included information provided about the hospital’s Patient, Advice and Liaison Service (PALS). Staff groups across the service told us they were encouraged to be engaged with the service and their views were reflected in service planning and delivery. Records also showed this. For example, staff forum meeting minutes dated January 2019 showed that staff had been asked for their opinions to improve the service. Staff gave us examples where their view had led to service change. This included a staff nurse whose idea had led to a change in a recent mouth care project. The mouth care project was planned for February 2019 where the service was trialling new mouth care products to improve the mouth comfort of level three patients. Throughout the service there were notice boards displaying up-to-date information for staff about the service. We also saw that at the start of medical and nursing handover there were updates given about the service. This included learning from recent incidents and changes. Monthly newsletters were distributed to all staff. We checked the last three CCC newsletters from November 2018 to January 2019. We saw that there were updates about the service including about the CCC’s mouth care awareness project, learning from incidents and welcomes to new staff joining the team.

Learning, continuous improvement and innovation The trust was committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation. The service had recently changed the four hour admission target to one hour. That is from time of critical care acceptance to admission. An audit was scheduled for May 2019 to determine compliance. A recent “Critical Care Flu Fighter Campaign” had been carried out whereby a group of nurses from the service offered staff flu vaccinations. Records showed that this campaign led to 90% of CCC staff being vaccinated by December 2018. Technology was used to support timely access to care and treatment. An electronic healthcare record (EHR) system specific to critical care was in place. This was used by the entire MDT. There was a consultant who was the lead for the system who completed modifications when asked. This system was consistently being adapted to improve care and treatment. The CCC was in the process of developing its own set values. Staff were being encouraged to give their ideas for these values. There was a bereavement service available for bereaved families following the loss of a loved one. The team consisted of two registered nurses who provided and sign posted additional support. There was strong emphasis on the safety and well-being of staff. Staff told us that there were staff running groups and regular activities arranged for the team. We also saw a staff room board displaying future planned social events.

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Doctors told us about a team of senior medical staff called the “fatigue team” who supported them in reducing fatigue levels due to work. Doctors told us that this team had helped them make improvements such as securing funding for black out blinds in their staff rooms. There was a training simulation room used for simulation practice. There was a state of the art manikin, hospital bed and the ability to film simulation practice. One of the CCC medical trainees led simulation training and was allocated to this role two days per week.

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Maternity

Facts and data about this service Norfolk and Norwich University Hospitals NHS Foundation trust provides community and hospital based midwifery and obstetric care, with services being provided at Norfolk and Norwich University Hospital. A list of services at the hospital can be found below. • Hospital antenatal clinic • An ultrasound department • A fetal medicine scanning area • Antenatal inpatient area: 14 beds • Maternity assessment area: three assessment beds • Delivery suite: 15 birthing rooms and two obstetric theatres • Midwifery birthing unit: Four rooms (three of which have birthing pools) • Postnatal ward: 32 beds (Source: Trust Provider Information Request – Acute sites)

The trust also employs community midwives, who provide care for women and their babies both during the antenatal and postnatal period and provide a home birth service. The community midwives are aligned to the local GP practices. From July 2017 to June 2018 there were 5,133 deliveries at the trust. A comparison from the number of deliveries at the trust and the national totals during this period is shown below. Number of babies delivered at Norfolk and Norwich University Hospitals NHS Foundation Trust – Comparison with other trusts in England.

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A profile of all deliveries and gestation periods from April 2017 to March 2018 can be seen in the tables below.

Profile of all deliveries (April 2017 to March 2018) NORFOLK AND NORWICH UNIVERSITY HOSPITALS NHS England FOUNDATION TRUST Deliveries Deliveries (n) Deliveries (%) (%) Single or multiple births Single 5,099 98.6% 98.6% Multiple 71 1.4% 1.4% Mother’s age Under 20 144 2.8% 3.1%

20-34 3,941 76.2% 74.9%

35-39 905 17.5% 18.1% 40+ 180 3.5% 4.0% Total number of deliveries Total 5,170 596,828

Notes: A single birth includes any delivery where there is no indication of a multiple birth. This table does not include deliveries where delivery method is 'other' or 'unrecorded'.

Gestation periods (April 2017 to March 2018) NORFOLK AND NORWICH UNIVERSITY HOSPITALS NHS England FOUNDATION TRUST Deliveries (n) Deliveries (%) Deliveries (%) Gestation period Under 24 weeks 0.1% Pre- term 24-36 weeks No deliveries at the trust had a 7.8% Term 37-42 weeks valid gestation period recorded. 91.9% Post Term >42 weeks 0.2%

Total number of deliveries with a valid gestation period recorded

Total 0 498,704 Notes: This table does not include deliveries where delivery method is 'other' or 'unrecorded'.

(Source: Hospital Episodes Statistics (HES) – Provided by CQC Outliers team) The number of deliveries at the trust by quarter for the last two years can be seen in the graph below.

Number of deliveries at Norfolk and Norwich University Hospitals NHS Foundation Trust by quarter.

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(Source: Hospital Episode Statistics - HES Deliveries (July 2017 - June 2018))

Is the service safe? By safe, we mean people are protected from abuse* and avoidable harm. *Abuse can be physical, sexual, mental or psychological, financial, neglect, institutional or discriminatory abuse. Mandatory training The service had a comprehensive training programme to provide staff with the training they required, however the trust target for attendance at training was not met by the service. The service had a poor rate of compliance with resuscitation training for medical staff of 53%. Doctors that we spoke with could not tell us whether they were up to date with this training and there was a lack of knowledge among medical staff around who was responsible for ensuring mandatory training was completed for medical staff. The trust set a target of 90% for completion of mandatory training. The service had an average completion rate of 79% for midwifery staff and 86% for medical staff and therefore did not meet their target. However, compliance rates had improved slightly since our previous inspection where there was an average completion rate of 72% for midwifery staff and 60.4% for medical staff. A breakdown of compliance for mandatory training courses at September 2018 at trust level for qualified midwifery staff in maternity is shown below:

Number Number of of staff eligible trained staff Completion Trust Met Name of course (YTD) (YTD) rate Target (Yes/No) Adult Basic Life Support 222 240 93% 90% Yes Resuscitation 221 240 92% 90% Yes Medicine management training 218 240 91% 90% Yes

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Infection Prevention (Level 2) 212 240 88% 90% No Blood Transfusion 176 203 87% 90% No Manual Handling - People 199 239 83% 90% No Health and Safety (Slips, Trips and Falls) 190 240 79% 90% No Equality and Diversity 172 240 72% 90% No Information Governance 164 240 68% 90% No Venous Thromboembolism 148 239 62% 90% No Fire Safety 136 240 57% 90% No

In maternity the 90% target was met for three of the 11 mandatory training modules for which qualified midwifery staff were eligible. A breakdown of compliance for mandatory training courses at September 2018 at trust level for medical staff in maternity is shown below:

Number Number of of staff eligible trained staff Completion Trust Met Name of course (YTD) (YTD) rate Target (Yes/No) Health and Safety (Slips, Trips and Falls) 44 45 98% 90% Yes Blood Transfusion 43 45 96% 90% Yes Medicine management training 42 45 93% 90% Yes Clinical Record Keeping 42 45 93% 90% Yes Infection Prevention (Level 3) 39 42 93% 90% Yes Fire Safety 41 45 91% 90% Yes Venous Thromboembolism 40 44 91% 90% Yes Adult Basic Life Support 40 45 89% 90% No Manual Handling - Object 35 42 83% 90% No Equality and Diversity 37 45 82% 90% No Information Governance 33 45 73% 90% No Resuscitation 16 30 53% 90% No

In maternity the 90% target was met for seven of the 12 mandatory training modules for which medical staff were eligible. Note: The training data for medical and dental staff in maternity incudes some staff who work across both maternity and gynaecology. (Source: Routine Provider Information Request (RPIR) – Training tab) The service used Practical Obstetric Multi-Professional Training (PROMPT) to deliver some of the maternity mandatory training. The topics covered by the PROMPT training included: fetal monitoring, inverted uterus, human factors, sepsis, Modified Early Obstetrics Warning Score, obstetric haemorrhage, shoulder dystocia, breech, eclampsia, twin birth and cord prolapse. The training was delivered by a multidisciplinary team and involved a mixture of skills and live drills sessions and presentations. The service’s mandatory training was a combination of face-to-face sessions and e-learning. The face-to-face training was a three-day programme which staff were expected to attend annually. This included the trust mandatory specific training and PROMPT. Medical staff, midwifery staff and

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 227 maternity care assistants were expected to attend. The trust provided us with data that showed 93.1% of medical and midwifery staff had attended the PROMPT training. The content of the training responded to recent incidents in the service. Staff provided us with an example where a baby had collapsed on the postnatal ward with an infection. The service added a presentation to the mandatory training day from a consultant paediatrician on recognising the deteriorating baby. The service had 2.4 whole time equivalent (WTE) practice development midwives (PDMs) who were responsible for developing the programme for mandatory training and the monitoring of midwifery attendance. The PDMs delivered training on the services PROMPT programme. Midwives and medical staff completed bi-annual, online cardiotocography (CTG) training and had to attend a CTG review meeting annually. The completion rates for this training was 100% for medical staff and 94.9% for midwifery staff against a target of 90%. The service was taking action to improve mandatory training rates including addressing non- compliance with mandatory training through capability procedures, increasing access to the online system and changing the way that mandatory training was rostered to improve attendance.

Safeguarding Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service had improved compliance rates with training on how to recognise and report abuse and staff knew how to apply it. However, the service’s medical staff were not trained to Level 3 Safeguarding children which was not compliant with national guidance.

Safeguarding training completion rates The trust set a target of 90% for completion of safeguarding training. There were mixed compliance results for the service. Midwifery and medical staff met the compliance target for Safeguarding children training. However, neither medical or midwifery staff met the target for safeguarding adults training or PREVENT training. Whilst the service had not met their target in four of the six areas, they had demonstrated an improvement in figures from the previous inspection in April 2017 where compliance levels were between 41.7% and 50% for Level 2 Children’s and adults safeguarding training. Service leads told us that they had plans in place to change the delivery of safeguarding training to a one-day course for both adult and children safeguarding to improve compliance levels across the service. The new course was due to commence in June 2019. A breakdown of compliance for safeguarding training courses at September 2018 at trust level for qualified midwifery staff in maternity is shown below: Number of staff Number of trained eligible Completion Trust Met Name of course (YTD) staff (YTD) rate Target (Yes/No) Safeguarding Children (Level 3) 221 240 92% 90% Yes Safeguarding Adults (Level 2) 183 240 76% 90% No PREVENT - Level 3 144 233 62% 90% No

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In maternity the 90% target was met for one of the three safeguarding training modules for which qualified midwifery staff were eligible. A breakdown of compliance for safeguarding training courses at September 2018 at trust level for medical staff in maternity is shown below: Number of Number of eligible staff trained staff Completion Trust Met Name of course (YTD) (YTD) rate Target (Yes/No) Safeguarding Children (Level 2) 40 44 91% 90% Yes PREVENT - Level 3 30 38 79% 90% No Safeguarding Adults (Level 2) 34 44 77% 90% No

In maternity the 90% target was met for one of the three safeguarding training modules for which medical staff were eligible. Note: The training data for medical in maternity incudes some staff who work across both maternity and gynaecology. (Source: Routine Provider Information Request (RPIR) – Training tab) Following our inspection, we requested that the trust provide us with information on Level 3 safeguarding children rates for doctors. The trust told us that the obstetricians were currently trained to safeguarding children level 2 only. This did not comply with the Safeguarding Children and Young People: Roles and Competencies for Healthcare staff, intercollegiate document, January 2019 which states that all clinical staff working with children who could potentially contribute to assessing, planning, intervening and/or evaluating the needs of a child or young person should be trained to Level 3. On our previous inspection we told the service that they must ensure staff completed appropriate mandatory training including safeguarding training to a level appropriate to their job role. The service had not complied with our requirement notice. However, the service had plans to train all medical staff to Level 3 as part of a new training regime commencing in June 2019. Safeguarding processes were used by staff to keep adults and babies safe from avoidable harm. All the staff we spoke to were able to give detailed explanation of their duties in relation to safeguarding concerns. The staff we spoke with were able to confidently inform us of what a safeguarding concern would be and their process for reporting this. If a safeguarding concern was identified by a member of staff then they would fill in a cause for concern form which would identify the level of risk and appropriate action to be taken such as a referral to children’s services, a pre-birth risk assessment or conduct a joint visit with the health visiting team. All cause for concern forms were sent to the services safeguarding midwife team to be reviewed and logged. The service had two safeguarding midwives who supported staff with referrals, pre-birth assessments, joint visits with health visitors and any queries they may have. The safeguarding midwives were present on the wards every weekday morning to ensure they were available to staff for any questions and to see women known to the service for safeguarding issues. Staff were aware of who the safeguarding team were and how to get in contact with them. The safeguarding midwives worked effectively with other stakeholders in the area including the local authority and other acute trusts to ensure that women and their babies were safeguarded from abuse. The safeguarding midwives regularly attended multi-agency meetings including

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 229 domestic abuse meetings with the local council, the local safeguarding board meetings and meetings related to child sexual exploitation and neglect. The service had made a total of 119 referrals to children’s service from January 2018 to January 2019. The service had robust arrangements in place to safeguard women with and at risk of Female Genital Mutilation (FGM). Women were asked at booking about FGM, if they had undergone this procedure staff referred women to the vulnerable women consultant and a pre-birth risk assessment would be completed. The service then worked closely with the trusts adult safeguarding team to put in place care plans and alerts. Midwifery staff were aware of the service’s FGM policy and could provide examples of when they had used it. The service held bi-weekly safeguarding meetings to discuss cases and ensure women’s needs were met. These were attended by the safeguarding lead midwife, the vulnerable women’s midwives, the family care team on the neonatal intensive care unit, the safeguarding lead from the community mental health trust and the trusts substance abuse liaison nurse. The service had processes in place to flag when a woman had children subject to a child protection plan. The services safeguarding midwife entered alerts onto the service electronic records system when children’s services were involved with the woman. The alerts provided contact details for the woman’s social worker and the full care plan for the woman and her unborn baby. Children’s services sent a list of all children and unborn children subject to a child protection plan to the safeguarding midwife weekly. The trust had a baby abduction policy and the service had conducted recent practice drills. Staff also told us that child sex exploitation (CSE) was a part of mandatory safeguarding training and the service had recently sent out a refresher email about looking for signs of CSE.

Cleanliness, infection control and hygiene The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection. We observed all the areas to be visibly clean. There was a robust system throughout the service to identify clean equipment by using ‘I am clean stickers’. All the equipment we viewed with these stickers had been cleaned within the previous 24 hours. We observed staff using personal protection equipment which was readily available to staff such as disposable gloves and aprons. We observed that all staff were bare below the elbow and performed hand washing before and after episodes of direct care. Hand sanitising units and handwashing facilities were available throughout the unit and handwashing prompts were visible for staff, women and the public. Hand hygiene audits were completed monthly. This involved staff being observed washing their hands after contact with women and ensuring staff were washing their hands according to the National Institute for Health and Care Excellence (NICE) guidance on effective hand decontamination. We saw that the results of the hand-hygiene audit were displayed on Cley ward and showed that they scored 100% for October 2018. The service also audited commode and bedpans for cleanliness. We saw that the service scored 100% in these audits from July 2018 to December 2018. The service monitored the instance of C. Difficile and Methicillin-resistant Staphylococcus aureus (MRSA) blood stream infections acquired by women when using the service. We saw that from December 2017 to December 2018 there were no instances of C.Difficile or MRSA.

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All women were screened for MRSA at booking. Where inpatient women had a known or suspected infection, they were cared for in single side rooms. We observed that sharps waste was appropriately managed. Sharps boxes for the disposal of needles were assembled, not over full, signed and dated. Housekeeping staff were responsible for daily cleaning schedules of clinical areas. These included the floors, bathrooms and specific equipment. We saw completed cleaning schedules for a seven- day period on Cley ward. The service had an external auditor which completed monthly audits on the cleanliness of the wards. If the service failed an area of the audit then they had to clean the area again and re-audit to ensure compliance. The service had a guideline for the management of women requesting immersion in water for active labour and/or birth, however the guideline did not provide clear advice on the cleaning of the service’s birthing pools. The guideline referenced a cleaning product to use but did not detail the solution to be used or how long the solution should be left to soak in the pool. We raised this with the trust who informed us that they would amend the guideline. Alcohol-based hand sanitisers were located at the entrance and exits to all maternity wards. However, we observed that the hand sanitiser at the entrance to the maternity unit was empty on day two of our inspection. We advised the service that it had run out and were given assurances that it would be refilled by staff.

Environment and equipment The service did not always have systems, processes and practices implemented in place to manage equipment to keep people safe. We found pieces of expired consumable equipment in the community setting and saw that resus trolleys were not always checked daily and their tagging system was not effective. The service had effective processes in place to ensure that consumable equipment was in date within the hospital setting; we checked twenty pieces of consumable equipment including syringes, needles and airways, all of which were in date. However, there was not an effective process in the community to ensure that equipment community midwives carried with them was in date. We found in one midwives car five pieces of expired consumable equipment including delivery packs and resuscitation masks. The service did not consistently check resuscitation trolleys daily. We observed that the resuscitation trolley on gynaecology outpatients (used by the antenatal clinic) and on the delivery suite had gaps in the checklist in the previous month. Midwifery staff on the delivery suite told us that the resuscitation trolley checklist was now completed 80-90% of the time. We noted that the resus trolley on Cley ward had been checked daily for the previous month. The trust had a system in place to prevent resuscitation trolleys from being tampered with however this was inconsistently applied across the service. The service had sealed tags with numbers on that they would replace after they had checked the contents of the resus trolley. The tag numbers should have been noted so that anyone checking the contents could be assured that the trolley had not been tampered with since the previous check. However, on Cley ward and outpatient gynaecology we saw that tag numbers were not noted and new tags were stored in the drawers. This meant that anyone could break the tag, tamper with the equipment or medicines and then replace the tag and this would not be traceable. We saw that on the delivery suite that the process was correctly completed in full, including the recording of the tag number.

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The service’s delivery suite had 15 rooms with access to ensuite bathrooms and one water birth pool. Next to the delivery suite were two obstetric operating theatres, one of which was for emergency procedures and one for elective procedures. The two dedicated theatres on the delivery suite meant that in the rare occasion two emergencies could be managed at the same time. The theatres were easily accessed on the delivery suite and the neonatal unit was nearby for timely transfers when required. The service had a midwifery led birthing unit (MLBU) with four birthing rooms with ensuite showers and toilets. The rooms were decorated with soft lighting and had audio equipment for women to bring in their own music to create a homely environment. Three of the four birthing rooms had birthing pools. Baby resuscitaires, (a specialist piece of equipment that is used for babies who may need some help with their breathing at birth), were available in every room within the delivery suite and were fully stocked, clean and ready for use. Community midwives had access to essential equipment such as baby scales, sonicaids, bilirubinometers and blood pressure machines with multiple sized cuffs. A bilirubinometer is a device that measures the amount of bilirubin in the blood which is a measure of jaundice in newborn babies. We checked nine pieces of electrical equipment across the service and saw that the equipment had been recently electrical tested and calibrated where relevant. We checked the services equipment register and saw that all pieces of electrical and medical equipment in the service had received preventative maintenance within the last year. Bariatric equipment could be hired if required and staff were aware of the process and had a suitable room to use the equipment on the post-natal ward.

Assessing and responding to patient risk Staff completed and updated risk assessments for each patient. They kept clear records and asked for support when necessary. We saw evidence of comprehensive risk assessments that had been carried out for women using the maternity service and plans which were developed in line with national guidance. Risk assessments took place at the time of booking (around 8-12 weeks of pregnancy). These included social and medical risk assessments. We observed that midwives carried out venous thromboembolism (VTE) risk assessments to identify women potentially at risk. A VTE is a life-threatening condition where a blood clot forms in a vein. The service was compliant with the World Health Organisations (WHO) surgical safety checklist that supported safer care and reduction in patient safety incidents. We observed part of a caesarean section list in theatre and saw that the checklist was completed appropriately. We saw evidence the ‘fresh eyes approach’ had been adopted in the interpretation of cardiotocography (CTG). CTG monitoring was used to monitor the fetal wellbeing for women that were assessed as being high risk, we saw evidence that staff performed hourly reviews with a colleague during labour. The service had a process in place to ensure that new-born babies had their NHS new-born and infant physical examination (NIPE) screening within 72 hours of birth. The NIPE screening test is a

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 232 process to check if the new-born baby has any problems with their eyes, heart, hips and genitalia. The service monitored the online NIPE system three times a day and used the Red-Amber-Green rating system to see when a new-born baby had not yet been screened. The service ran NIPE clinics on Blakeney ward daily to ensure that babies were screened within 72 hours. Women in active labour were monitored using partogram sheets. The partogram monitored key data during labour such as cervical dilation, fetal heart rate, vital signs and duration of labour. We reviewed five partograms and saw that they were fully completed. Women on the postnatal ward were monitored using the Modified Early Obstetric Warning Score (MEOWS). The MEOWS is a screening tool intended to improve the response to a physiological deterioration in the pregnant woman. We observed five charts on Blakeney ward and saw that these were completed in full. Staff told us that following a recent incident with MEOWS they had changed the escalation procedure so that a score of more than one would be reported to the midwife caring for the woman. Babies on the delivery suite and postnatal ward were monitored using the Newborn Early Warning Trigger and track. There were ’safe hands’ meetings to discuss any incidents in the previous 24 hours at the beginning of morning handovers on the delivery suite on weekdays. Staff within the service did not know why the meetings did not occur at weekends. The service also held daily safety huddles at 10am attended by obstetricians, midwives and the neonatal intensive care unit staff to discuss the acuity of the delivery suite and the capacity of the unit. The service’s medical team conducted a daily ward round on the delivery suite. A multidisciplinary board round also took place on the delivery suite in the morning where women on the unit were discussed. Midwives gave verbal handover when taking over a woman’s care. The service had developed SBAR (situation, background, assessment, recommendation) stickers, a technique used to facilitate prompt and appropriate communication. The services maternity assessment and triage area had a system of rating women and red, amber or green (RAG rating) to determine whether they needed to be escalated to the delivery suite. This meant that women who were in advanced stages of labour or deemed high-risk were prioritised by the service. Junior staff that we spoke to told us that they felt confident in escalating concerns and deteriorating women to a consultant or senior midwifery staff and that the consultants were responsive and there were no delays when they were called. The service did not have a high dependency unit for women on the delivery suite. Women who became seriously ill were transferred to the hospital’s critical care unit. The service had created a business case for the creation of a high dependency unit and were looking at the staff competencies necessary to staff the unit. On our previous inspection we noted that when women called the service for advice that only a paper record of this was taken and if the same person called several days in a row then this information would not be available to those answering the call. On this inspection we saw that the service now recorded these calls on the woman’s electronic records meaning that this information was available to all staff.

Midwifery and nurse staffing

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The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.

Planned vs actual The trust has reported their staffing numbers at March 2018 and at September 2018 for qualified nursing and midwifery staff in maternity. The number of actual staff was lower by 8.7 WTE staff in September 2018 compared to March 2018. As of September 2018, the fill rate for qualified nursing and midwifery staff in maternity was 92.6%.

As at March 2018 As at September 2018 Planned Planned Actual staff – Fill Fill staff – Actual staff – WTE staff – WTE rate rate Site WTE WTE Trust wide 209.6 216.9 96.7% 200.9 217.1 92.6% (Source: Routine Provider Information Request (RPIR) – Total staffing tab)

Vacancy rates From September 2017 to August 2018, the trust reported a vacancy rate of 3.5% for qualified nursing and midwifery staff in maternity. The trust does not have a target for vacancy rate. (Source: Routine Provider Information Request (RPIR) – Vacancy tab)

Turnover rates From October 2017 to September 2018, the trust reported a turnover rate of 9.4% for qualified nursing and midwifery staff in maternity. This was lower than the trust target of 10.0%. (Source: Routine Provider Information Request (RPIR) – Turnover tab)

Sickness rates From September 2017 to August 2018, the trust reported a sickness rate of 6.1% for qualified nursing and midwifery staff in maternity. This was greater than the trust target of 3.5%. (Source: Routine Provider Information Request (RPIR) – Sickness tab)

Bank and agency staff usage From September 2017 to August 2018, the trust reported that 23,874 of the 478,810 establishment hours were filled by bank staff (5.0%) and 134 hours were filled by agency staff (<0.1%). There were no hours that needed to be covered by bank or agency that were left unfilled. A breakdown of bank and agency usage by staff type is shown below: Total establishment Staff type Bank hours Agency hours Unfilled hours hours Qualified 10,190 (2.6%) 0 (0%) 0 (0%) 390,950 Non-qualified 13,684 (15.6%) 134 (0.2%) 0 (0%) 87,859 Total 23,874 (5.0%) 134 (<0.1%) 0 (0%) 478,810 (Source: Routine Provider Information Request (RPIR) - Nursing bank agency)

Midwife to birth ratio

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From July 2017 to June 2018, the trust had a ratio of one midwife to every 25.3 births. This was similar to the England average of one midwife to every 25.5 births. (Source: Electronic Staff Records – EST Data Warehouse) The service used a national tool to calculate the staffing necessary on the delivery suite. The delivery suite coordinator used the tool at each shift change and would flag where the service had staffing issues. Midwifery staff told us that to fill any staffing shortfalls the service would move staff from other areas in the service to support the delivery suite or call in bank staff. On the day of our inspection the delivery suite was short of three midwives. One midwife had had their study day cancelled to work on the delivery suite giving the suite six midwives. The shift coordinator had assessed this as sufficient for the number and acuity of the women on the delivery suite. At the time of our inspection the service had purchased a new national tool to calculate the acuity of women on a shift by shift basis to assist with planning staffing levels, however this was not yet in use on the delivery suite. The service was also submitting its staffing data to a national database to compare their staffing levels and acuity with similar services. We were concerned that the services dashboard showed that one to one care in labour had been achieved in 91.8% of cases on average. The national institute of clinical excellence quality standard (QS105) states that women in established labour have one-to-one care and support from an assigned midwife. We raised this concern with the head of midwifery who told us that the statistics were not accurate and that midwives were not recording a true reflection of their activity which did meet the guidance for one to one care. In response to this concern the service was educating midwives on the meaning of one to one care. Midwifery staff that we spoke to told us that they were happy with the staffing levels in the service and felt they could access bank staff whenever necessary. However, multiple members of midwifery staff told us that they were concerned about the skill mix of the midwives as the workforce was relatively junior. The service had eight community midwifery teams with 55 whole time equivalent (WTE) midwives against a target of 59 WTE community midwives. The service provided a home birth service to women. Midwives on the home birth rota worked in a supernumerary capacity on the midwifery led unit whilst on call to ensure that they updated their skills and competencies. The service’s arrangements for handover ensured that people were safe. The service had a midwifery handover at 7am followed by a medical handover at 7:30am. The service then held a safe-hands meeting every weekday at 7:45am which was multidisciplinary and discussed a case from the previous 24 hours to highlight learning or improvements. We saw that midwifery staffing numbers were displayed on Blakeney ward on the days of our inspection and that the staffing numbers matched the expected levels.

Medical staffing The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. The trust has informed us that they are not able to separate medical staff working in maternity and gynaecology. For this reason, the data below includes medical staff that work in both core services.

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The trust has reported their staffing numbers at March 2018 and at September 2018 for medical staff in maternity. As at September 2018, the trust was at establishment (fill rate of 101.5%) for medical staff in maternity.

As at March 2018 As at September 2018 Planned Planned Actual staff – Fill Actual staff – Fill staff – staff – WTE rate WTE rate Site WTE WTE Trust wide 56.3 57.0 98.7% 58.1 57.2 101.5% (Source: Routine Provider Information Request (RPIR) – Total staffing tab)

Vacancy rates From September 2017 to August 2018, the trust reported a vacancy rate of 1.8% for medical staff in maternity. The trust does not have a target for vacancy rate. (Source: Routine Provider Information Request (RPIR) – Vacancy tab)

Turnover rates From October 2017 to September 2018, the trust reported a turnover rate of 0.0% for medical and dental staff in maternity and gynaecology. This is lower than the trust target of 10.0%. (Source: Routine Provider Information Request (RPIR) - Turnover tab)

Sickness rates From September 2017 to August 2018, the trust reported a sickness rate of 1.0% for medical staff in maternity. This was lower than the trust target of 3.5%. (Source: Routine Provider Information Request (RPIR) – Sickness tab)

Bank and locum staff usage From September 2017 to August 2018, the trust reported that 3,470 of the 119,303 establishment hours were filled by bank staff (2.9%) and 645 hours were filled by medical locum staff (0.5%). There were no hours that needed to be covered by bank or medical locum staff that were unfilled. A breakdown of bank and medical locum usage by unit/ward is shown below: Total Locum establishment Unit/ward Bank hours hours Unfilled hours hours Obstetrics & Gynaecology 3,470 (2.9%) 645 (0.5%) 0 119,303 Total 3,470 (2.9%) 645 (0.5%) 0 119,303

(Source: Routine Provider Information Request (RPIR) – Medical agency locum tab)

Staffing skill mix As at July 2018, the proportion of consultant staff reported to be working at the trust was higher than the England average and the proportion of junior (foundation year 1-2) staff was lower.

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Staffing skill mix for the 48.5 whole time equivalent staff working in maternity at Norfolk and Norwich University Hospitals NHS Foundation Trust. This England Trust average Consultant 51% 41% Middle career^ 8% 9% Registrar group~ 37% 43% Junior* 4% 6%

^ Middle Career = At least 3 years at SHO or a higher grade within their chosen specialty ~ Registrar Group = Specialist Registrar (StR) 1-6 * Junior = Foundation Year 1-2 (Source: NHS Digital Workforce Statistics)

Medical staffing was planned and reviewed to enable women to receive care and treatment by the correct grade of medical staff, support was available from a team consisting of a consultant, a middle grade doctor and a junior doctor. Consultant obstetricians were rostered for delivery suite for 98 hours per week, which was more than the national recommendation of 40 hours by the RCOG; Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in Labour 2007. There was a good level of consultant cover across the service. There was a separate consultant on call for gynaecology which meant that the consultant on call for the labour ward could ensure they were available. Consultants completed a daily ward round on the delivery suite, antenatal ward and postnatal ward. There was an anaesthetist present on the delivery suite from 7:30am to 6pm during weekdays with on call support out of hours and at weekends.

Records Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date and easily available to all staff providing care. However, records were not always stored in a way that protected patient confidentiality. We were not assured that women’s records were stored in a manner to protect their confidentiality. We saw that records were stored on Cley ward in the corridor in an unlocked cabinet. This was an issue that we had raised with the service on our previous inspection that had not been resolved. Records were a combination of electronic and paper based. Records of women’s community and hospital antenatal care were recorded on the services electronic system. Women received a paper based personal health record to keep details of their baby’s development and take with them to future baby appointments and reviews. Staff completed the sections they were required to.

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During our inspection we viewed 11 care records of women who had used the maternity service in the previous 48 hours or whom were still on the ward at time of inspection and found them to be contemporaneous, legible, dated and signed. All records had risk assessments carried out at booking and a venous thromboembolism (VTE) risk assessment was completed for each person admitted to the maternity unit. Women’s choices and preferences were documented clearly and information regarding prescription medication, alcohol intake, medical history and additional needs was completed fully. On discharge home, an electronic summary was immediately posted to the General Practitioner, the Health Visitor and copy in the medical records to hand over care to the appropriate health professionals. The service had completed several recent audits on record keeping, including audits on record keeping of fresh eyes and completion of cardiotocography stickers, modified early obstetric warning score and the Gestation Related Optimal Weight(GROW). Grow charts plot the fundal height and estimated fetal weight of a baby to monitor its development. We saw that the audits identified areas for improvement and actions to be taken.

Medicines The service did not always follow best practice when storing medicines. The service could not access variable speed infusion pumps on the delivery suite during our inspection and we found expired intravenous fluids in the community setting. During our inspection there was a shortage of variable speed infusion pumps available for the administration of syntocinon on the delivery suite. Syntocinon can used during and immediately after delivery to help the birth and to prevent or treat excessive bleeding. The delivery suite did not have access to their own supply of pumps and instead had to request them from the central equipment stores. Midwifery staff told us this caused delays in receiving the pumps and issues with not being able to access the pumps at all when the acuity levels in the hospital were high. This posed a risk that if a woman was to have an emergency haemorrhage (excessive bleed) post-delivery then syntocinon would not be administered using a pump to treat the haemorrhage. Midwives told us that in an emergency haemorrhage situation they would administer syntocinon using an intravenous drip (IV) and a counting method which would not be as accurate but still effective. We identified issues with the management of medicines in the community setting. Community midwives would take oxytocic medicines from the medicines fridge but they did not note the date that they had taken the medicines. Oxytocic medicines are used for several indications in obstetrics including induction of labour and to manage post-partum haemorrhage. Oxytocic medicines have a shelf-life of between six to eight weeks when not refrigerated. Therefore, without noting when the medicine had been taken out of the fridge, the midwives were unable to ascertain when they had expired and risked giving women medicine that had expired. The service stored medical gases such as oxygen and Entonox (a gas used for pain relief in labour) appropriately onsite in the hospital, however there was not appropriate storage of Entonox in the community. Midwives in the community stored Entonox in their cars and told us that the Entonox cylinders remained in their cars, stored on their side which was not in accordance with manufacturer guidance on the storage of medical gases.

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A further issue we found in the community setting was expired intravenous (IV) fluids that were stored in a community midwife’s car. This posed a risk that expired fluids could have been administered to a woman. Fridges that contained medicines were locked however the fridges were not consistently checked daily for temperature on either Blakeney ward, Cley ward or the delivery suite. We also saw that ambient room temperature checks for treatment rooms were not checked consistently. The temperatures that had been recorded showed no indications that were outside of safe storage of medicine. We had raised this as a requirement notice on our previous inspection and told the trust that they must ensure medication is stored in line with trust policy and that staff record medicine refrigeration temperatures to ensure the safe storage of refrigerated medication. We reviewed five electronic prescription charts and saw that personal information and allergies were documented. Controlled drugs were checked twice daily by two registered midwives to ensure the correct stock was present. This was recorded and logged in accordance with Trust policy. The service had pharmacist support for medicines and the pharmacist would visit the wards and delivery suite weekly to identify medicines that were low in stock and check their expiry dates. We saw that emergency medicines stored on resus trolleys were in date.

Incidents The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support. Staff we spoke with understood their responsibilities to raise concerns, to record safety incidents and near misses. There was a good culture of incident reporting and staff understood how to report an incident and where to locate the trust policy on incident reporting. Learning from incidents was shared via email, in daily ward safety huddles, handovers, organisation wide learning posters and email alerts and the daily safe hands meeting. Feedback for staff directly involved in incidents was shared through outcome reports sent by email. Leaders within the service attended the trusts daily serious untoward incident group to discuss any incidents that had occurred that were graded as moderate or above. The leads in the service would then share the learning from these meetings with their wider team. Staff we spoke with in the organisation could give examples of learning from incidents. One midwife told us about additional training provided for staff following a deteriorating baby in the recovery suite. Another midwife told us that guidelines were changed in the organisation following the readmission of a baby. Staff we spoke with had a good understanding of the duty of candour and could give examples of incidents where it had been applied. The duty of candour applies to registered professionals and dictates that staff must be open and honest with service users and other relevant persons, when things go wrong with care and treatment, giving them reasonable support, truthful information and an apology. The service held monthly mortality and morbidity meetings as part of the services clinical governance meetings in which they would discuss cases and present any learning identified.

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Never Events Never events are serious incidents that are entirely preventable as guidance, or safety recommendations providing strong systemic protective barriers, are available at a national level, and should have been implemented by all healthcare providers. From November 2017 to October 2018, the trust reported no incidents that were classified as never events for maternity. (Source: Strategic Executive Information System (STEIS))

Breakdown of serious incidents reported to STEIS A serious incident (is an incident where one or more patients, staff members, visitors or member of the public experience serious or permanent harm, alleged abuse or a service provision is threatened). We reviewed three serious incident investigations and found that there was a multidisciplinary approach to the investigation, a root cause analysis was performed to identify learning and arrangements for shared learning and action plans were documented. In accordance with the Serious Incident Framework 2015, the trust reported eight serious incidents (SIs) in maternity which met the reporting criteria set by NHS England from November 2017 to October 2018. The breakdown by incident type was as follows: Maternity/Obstetric incident meeting SI criteria: baby only (this include foetus, neonate and infant) with three (38% of total incidents). • Maternity/Obstetric incident meeting SI criteria: mother and baby (this include foetus, neonate and infant) with two (25% of total incidents). • Confidential information leak/information governance breach meeting SI criteria with one (13% of total incidents). • Screening issues meeting SI criteria with one (13% of total incidents). • Maternity/Obstetric incident meeting SI criteria: mother only with one (13% of total incidents). (Source: Strategic Executive Information System (STEIS))

Safety thermometer Staff collected safety information but it was not routinely shared with staff, patients and visitors. The maternity safety thermometer is a measurement tool for improvement that focuses on: post birth blood loss over 500ml, perineal tears (tears to the area between the vagina and rectum during birth), maternal infection, the psychological well-being of the mother and the baby’s health scores in the first 10 minutes after birth. Midwifery staff told us that the safety thermometer was not completed regularly and not displayed anywhere within the service. We reviewed the services thermometer data and saw that data had not been submitted for four months out of twelve. The safety thermometer was not regularly discussed at any of the services departmental or governance meetings.

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Is the service effective? Evidence-based care and treatment The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance. The service had a policy and process in place to ensure that they monitored compliance with guidance from the National Institute of Clinical Excellence (NICE). The trust’s clinical audit team emailed the service’s clinical lead when new guidance was published. The service’s clinical lead was responsible for reviewing the new NICE guidance and assessing relevance, conducting an organisational gap analysis of current practice against the recommendations and identifying shortfalls as required. The clinical lead was then responsible for confirming the compliance status and any associated risks. We saw that discussions of national guidance took place at the service’s monthly guideline meetings. The meetings looked at new guidance and tracked the trusts progress with writing guidelines and compliance. The service was not compliant with three pieces of NICE guidance including NICE guideline 27 weight management before during and after pregnancy and NICE guidance NG 25 Preterm labour and birth. The service’s compliance gap featured on the services risk register alongside action plans to mitigate the risk and work towards compliance. Women accessed antenatal appointments in line with the NICE Antenatal Care Quality Standard 22. This quality standard covers the antenatal care of all pregnant women up to 42 weeks of pregnancy in all settings that provide routine antenatal care. This includes primary, community and hospital-based care. Guidelines were easily accessible on the trust intranet for staff to access. We reviewed five guidelines, all of which were in date and referenced national guidance and best practice. However, the service did not have a guideline for concealed pregnancy or women who hadn’t been booked with the service. Midwives we spoke with could describe what they would do in the event of a concealed pregnancy or a woman that hadn’t been booked but without a guideline there was a risk of inconsistency in approach. The service focused on improving their provision for women experiencing mental health issues. The service were in the process of writing a mental health care pathway which was due to be ratified the week of our inspection. We saw that the services quality improvement projects had resulted in new technology being provided to staff to assess babies and prevent admissions. The services work on the avoiding term admissions into neonatal units (ATAIN) project had resulted in the purchasing of bilirubinometers which allowed community midwives to check a baby’s jaundice levels. The midwives would refer babies with jaundice over a certain level into the neonatal unit whereas before all babies with jaundice would be referred to the unit.

Nutrition and hydration Staff gave patients enough food and drink to meet their needs and improve their health. The maternity service had achieved UNICEF Baby Friendly Initiative (BFI) Level 3. This is a worldwide initiative to promote healthier feeding practices and improve standards of feeding for all

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 241 babies. The service had over 100 midwives trained to be BFI champions to assist and support women with infant feeding. An infant feeding support team provided training for staff to enable all staff to support women in their feeding choice. The team consisted of two band six and one band seven midwife. The team supported women on the post-natal ward and in the community with feeding support alongside running a weekly specialist infant feeding clinic alongside a lactation consultant and provided training courses on infant feeding for the wider midwifery team. All expressed breast milk (EBM) was stored in the fridge, was labelled with the date and woman’s name and kept for no more than three days in line with current guidance. The fridge was locked room which meant milk could not be taken or tampered with.

Pain relief Staff assessed and monitored patients regularly to see if they were in pain. They supported those unable to communicate using suitable assessment tools and gave additional pain relief to ease pain. Women had a choice of pain relief and they could use the birthing pool if assessed as a low risk pregnancy. Women had the option to use nitrous oxide and oxygen mixture (Entonox) gas, intra muscular opioid injections and epidurals in accordance with national guidance NICE CG190 Intrapartum care 2017. There were no hypnobirthing options or alternative therapies in practice for women to access. Women we spoke with told us their pain was managed well by the service and they had been offered pain relief and did not have to wait to receive it. The service was in the process of auditing their waiting times for epidural anaesthesia in order to see where improvements could be made.

Patient outcomes Managers monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them. The service used a maternity dashboard to monitor outcomes, the dashboard for 2018 to 2019 was not colour rated green, amber and red in line with Royal College of Obstetricians and Gynaecologists guidance, which meant that it was not easy to identify compliance comparable to national or trust expected standards. The service offered antenatal screening to all women for HIV, Hepatitis B and syphilis, they achieved 97.9% compliance against a target of 95%. The new-born and infant physical examination screening programme (NIPE) is one of the antenatal and new-born NHS population screening programmes. NIPE screens new-born babies within 72 hours of birth, the service was 94.5% compliant against a target of 95%.

National Neonatal Audit Programme The table below summarises Norfolk and Norwich University Hospital’s performance in the 2017 National Neonatal Audit Programme against measures related to maternity care.

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Metrics Hospital Comparison to Meets national (Audit measures) performance other hospitals standard? Are all mothers who deliver babies from 24 to 34 weeks gestation inclusive given any dose of antenatal steroids? Within expected 84.0% (Antenatal steroids reliably reduce the range  chance of babies developing respiratory distress syndrome and other complications of prematurity) Are mothers who deliver babies below 30 weeks gestation given magnesium sulphate in the 24 hours prior to delivery? No current (Administering intravenous 76.7% Better standard magnesium to women who are at risk of delivering a preterm baby reduces the chance that the baby will later develop cerebral palsy) (Source: National Neonatal Audit Programme) The service had an action plan to monitor and improve their compliance with the National Neonatal Audit Programme. The plan assigned actions to named members of staff and tracked progress. Actions included doing an audit of non-compliant cases, feedback posters for staff and local learning presentations. The service was also part of the ‘Preventing cerebral palsy in preterm labour’ (PReCePT) pilot, working with the Eastern Academic Network to improve the neuro protection of preterm babies.

National Maternity and Perinatal Audit Programme The table below summarises Norfolk and Norwich University Hospital’s performance in the 2017 National Maternity and Perinatal Audit Programme against measures related to maternity care. The service performed within the expected range for five of the measures, however the service had a higher than expected proportion of women with severe post-partum haemorrhage of greater than or equal to 1500 ml. Metrics Hospital Comparison to Meets national (Audit measures) performance other hospitals standard? Trust-level case ascertainment (Proportion of eligible cases included 98.5% N/A ✓ in the audit) Antenatal measures (before birth, during or relating to pregnancy) Case-mix adjusted proportion of small-for-gestational-age babies (birthweight below 10th centile) who are not delivered before their Within expected No current 55.8% due date range standard (Babies who are small for their age at birth are at increased risk of problems before, during and after birth) Intra-partum measures (during labour and birth)

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Case-mix adjusted proportion of elective deliveries (caesarean or induction) between 37 and 39 weeks with no documented clinical indication for early delivery (For babies with a planned (or Lower than No current elective) birth, being born before 39 21.0% expected standard weeks is associated with an increased risk of breathing problems. This can lead to admission to the neonatal unit. There is also an association with long term health and behaviour problems) Case-mix adjusted overall caesarean section rate for single, term babies (The overall caesarean section rate is Within expected No current 24.9% adjusted to take into account range standard differences which may be related to the profile of women delivering at the hospital) Case-mix adjusted proportion of single, term infants with a 5-minute Apgar score of less than 7 (The Apgar score is used to summarise the condition of a new- born baby; it is not always a direct Within expected No current 1.4% consequence of care given to the range standard mother during pregnancy and birth, however a 5 minute Apgar score of less than 7 has been associated with an increased risk of problems for the baby) Case-mix adjusted proportion of vaginal births with a 3rd or 4th degree perineal tear (Third or fourth degree tears are a Within expected No current major complication of vaginal birth. 4.5% range standard Only tears that are recognised are counted therefore a low rate may represent under-recognition as well as possible good practice) Case-mix adjusted proportion of women with severe post-partum haemorrhage of greater than or equal to 1500 ml (Haemorrhage after birth is a major Higher than No current source of ill health after childbirth. 3.6% expected standard Blood loss may be estimated by visual recognition or by weighing lost blood. High rates may be due to more accurate estimation and low rates due to under recognition) Post-partum measures (following birth)

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Proportion of live born babies who received breast milk for the first feed and at discharge from the maternity unit Middle 50% of No current 79.0% (Breastfeeding is associated with hospitals standard significant benefits for mothers and babies. Higher values represent better performance) (Source: National Maternity and Perinatal Audit Programme) The service had formulated an action plan based on the recommendations of the audit and the progress had been presented to the trust’s safety sub board.

Standardised Caesarean section rates and modes of delivery From April 2017 to March 2018, the total number of caesarean sections was as expected. The standardised caesarean section rates for elective sections and rates for emergency sections were as expected.

Standardised caesarean section rate (April 2017 to March 2018) NORFOLK AND NORWICH UNIVERSITY HOSPITALS NHS England Type of FOUNDATION TRUST caesarean Caesarean Caesareans Caesarean Standardised RAG rate (n) rate Ratio Elective Similar to 12.4% 712 13.8% 113.7 (z=1.2) caesareans expected Emergency Similar to 15.9% 771 14.9% 94.3 (z=-0.4) caesareans expected Similar to Total caesareans 28.3% 1,483 28.7% 102.7 (z=0.4) expected

Source: Hospital Episode Statistics, April 2017 to March 2018

Notes: Standardisation is carried out to adjust for the age profile of women delivering at the trust and for the proportion of privately funded deliveries. Delivery methods are derived from the primary procedure code within a delivery episode.

In relation to other modes of delivery from April 2017 to March 2018 the table below shows the proportions of deliveries recorded by method in comparison to the England average:

Proportions of deliveries by recorded delivery method (April 2017 to March 2018) NORFOLK AND NORWICH England UNIVERSITY HOSPITALS NHS Delivery method FOUNDATION TRUST Deliveries Deliveries (n) Deliveries (%) (%) Total caesarean sections1 1,483 28.7% 28.3% Instrumental deliveries2 639 12.4% 12.4% Non-interventional deliveries3 3,048 59.0% 59.3% 100% Total deliveries 5,170 100% (n=596,828) Source: Hospital Episode Statistics, April 2017 to March 2018

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Notes: This table does not include deliveries where delivery method is 'other' or 'unrecorded'. 1Includes elective and emergency caesareans 2Includes forceps and ventouse (vacuum) deliveries 3Includes breech and normal (non-assisted) deliveries

The distribution of delivery methods at the trust was similar to the England averages from April 2017 to March 2018. (Source: Hospital Episodes Statistics (HES) – provided by CQC Outliers team)

Maternity active outlier alerts As of December 2018, the trust reported no active maternity outliers. (Source: Hospital Evidence Statistics (HES) – provided by CQC Outliers team)

MBRRACE-UK Perinatal Mortality Surveillance Report The table below summarises the trust’s performance in the 2017 MBRRACE-UK Perinatal Mortality Surveillance Report for births in 2016. Comparison to other trusts Metrics Trust Meets national with similar (Audit measures) performance standard? service provision Stabilised and risk-adjusted perinatal mortality rate (The death of a baby in the time Up to 10% lower period before, during or shortly after than the birth is a devastating outcome for No current 6.18 average for the families. There is evidence that the standard comparator UK’s death rate varies across regions, group even after taking into account differences in poverty, ethnicity and the age of the mother.) (Source: MBRRACE-UK) The service had formulated an action plan based on the recommendations of the audit and progress had been presented to the trust’s safety sub board. The action plan had a named member of staff responsible for delivering the actions. The service had an extensive programme of local audit. There was an evaluation of midwifery and obstetric care through continuous audit to improve outcomes. All junior medical staff were expected to take part in the service’s audit and were assigned a specific audit to perform by their college tutor. Audits were tracked at the service’s clinical governance meetings and the service held a central tracker spreadsheet which listed who was responsible for the audit and the progress. Audits within the department included audit of neonatal hypoglycaemia (low blood sugar levels), audit of re-admissions under 28 days and audit of venous thromboembolism. We reviewed three audit reports including an audit on the Modified Early Obstetric Warning Score, postnatal re-admissions under 28 days and staff knowledge of diabetes and pregnancy. We saw that local audits identified areas for improvements and had action plans with assigned members of staff responsible for delivery.

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We saw in the meeting minutes that both national and local audit outcomes were presented to the services clinical audit meetings to share learning. The service was using the National Perinatal Mortality Review tool to review all perinatal deaths. The service had reviewed four cases using the tool. The service had liaised with the local midwifery system, which was part of the area’s sustainability and transformation partnership, and had decided to introduce an external member to the panel to increase impartial scrutiny. The service has been submitting data to the Maternity Services Data Set (MSDS) and met nine out of ten of the criteria in line with the national standard. MSDS is a patient-level data set that captures key information at each stage of the maternity care pathway including mother’s demographics, booking appointments, admissions and re-admissions, screening tests, labour and delivery along with baby’s demographics, admissions, diagnoses and screening tests.

Competent staff The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service. The service had a comprehensive induction programme for midwives and midwifery care assistants. The midwifery programme involved being assessed for competencies relevant to the role such as perineal suturing, GROW competency and held scanning. Staff had the right skills and competencies to manage women with additional needs. The specialist midwives provided training to midwifery staff to equip them with specialist knowledge to complete their roles. The service’s vulnerable women midwives provided training to staff on recognising and supporting women with peri-natal mental health issues. The service’s infant feeding lead had trained 98 midwives to recognise tongue tie in babies. The service’s bereavement midwife had recently started to facilitate training for midwives and nurses on providing sensitive, parent-centred care for families who experienced a miscarriage, stillbirth or baby loss within the first year of life. Staff had also been offered training from the stillbirth and neonatal death charity (Sands). The services offered a range of support for professional revalidation including support from the practice development midwives, ex midwifery supervisors and the trust-wide practice development team. The practice development team had provided workshops on revalidation that were open to all staff to attend. The service ensured that bank staff were competent for their roles by providing the same induction, mandatory training and PROMPT training that permanent midwifery staff received. Midwifery support workers were encouraged to complete additional training to ensure they were competent in their role such as competency study days for recognising deteriorating women. Junior doctors within the service told us that they were happy with the training and support provided by the trust. The service held teaching sessions for junior doctors every Friday afternoon and junior doctors told us that they had regular and meaningful meetings with their educational supervisors.

Appraisal rates

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The trust provided us with data that showed the service had an appraisal rate of 94.6% for medical staff and 95% for midwifery staff in the maternity department. This exceeded the trust’s target of 90%. All staff we spoke with told us that they had a recent appraisal and had found the appraisal process meaningful. One member of staff gave examples of how their appraisal was tailored to their role and how they achieved their goals and competencies as a leader. Midwifery staff told us that they had monthly one to ones with their managers.

Multidisciplinary working Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care. Throughout the unit staff were proud of their multidisciplinary team (MDT) working and we observed that staff were respectful of one another. All staff we spoke with said that they worked well together, at the board round and handovers we attended we observed good communication and interactions within the multidisciplinary team. Community midwives told us they had good communication and working relationships with their community colleagues such as health visitors, family nurse practitioners, GP’s and social services. This ensured detailed handovers of care. Antenatal clinics held specialist clinics with midwives and consultants from different specialties with a multidisciplinary approach to co-ordinated care. This included a vulnerable women’s clinic held with a psychiatrist from the local mental health trust, the vulnerable women midwives and the services vulnerable women consultant. The service also held a gestational diabetes clinic with diabetic nurses, endocrinologists (An endocrinologist is a doctor that treats diseases related to problems with hormones) and the midwifery and obstetric team. Consultants led a ‘safe hands’ meeting on the delivery suite on weekday morning with input from the practice development midwives to provide multidisciplinary learning for all members of the delivery suite team.

Seven-day services There was access to medical staff cover 24 hours a day with 98 hours of consultant presence on the delivery suite. Middle grade medical staff told us that consultants would respond quickly when they were on call. Staff had access to diagnostic services such as x-ray, ultrasound, computerised tomography (an imaging procedure that uses special x-ray equipment to create detailed pictures, or scans, of areas inside the body), echocardiography (a sonogram of the heart) and pathology when needed. The pregnancy triage unit and day assessment unit provided support for women from 16 weeks of pregnancy, 24 hours a day, seven days a week. The service’s Early Pregnancy Unit was open seven days a week from 8am to 6pm on weekdays and from 8am to 12pm on Saturday and Sunday. Out of hours women would attend the emergency department and stay overnight on the trust’s gynaecology ward. Community midwives provided a seven-day, 24-hour home birth service.

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Health promotion Community midwives assessed women at the initial booking visit and offered the following support throughout the pregnancy if identified; weight management, smoking cessation advice and infant feeding advice. Influenza and whooping cough vaccines were offered to all pregnant women after 20 weeks gestation, to all women in antenatal clinics both in the community and the hospital. We saw posters promoting these vaccines. There was a prompt on the services computerised system for every antenatal contact. Women were offered screening for sexually transmitted diseases at booking. Any positive results would be managed by the ante-natal screening midwife who contacted the woman to arrange an appointment for discussion and treatment. Community midwives ran a programme of antenatal classes in the community which involved understanding pregnancy, labour, birth and baby care. The sessions were multidisciplinary and ran in conjunction with two other acute trusts in the local area. The service monitored the woman’s smoking status at booking and at time of delivery. The services smoking at delivery rates were 9.9% from April to December 2018. This was lower than the national average of 10.8% (NHS Digital Statistics on Women’s Smoking status at time of Delivery, England- Quarter 3, 2017-2018).

Consent, Mental Capacity Act and Deprivation of Liberty Safeguards Staff understood how and when to assess whether a patient had the capacity to make decisions about their care. They followed the trust policy and procedures when a patient could not give consent.

Mental Capacity Act and Deprivation of Liberty training completion The trust set a target of 90% for completion of Mental Capacity Act (MCA) and Deprivation of Liberty training. We requested the compliance rate with DoLS and MCA training after our inspection and saw that compliance had increased to 96.6% of staff which exceeded the trust’s target of 90%. A breakdown of compliance for Mental Capacity Act (MCA) and Deprivation of Liberty Safeguarding (DoLS) courses at September 2018 for qualified midwifery staff in maternity is shown below: Number of staff Number of trained eligible Completion Trust Met Name of course (YTD) staff (YTD) rate Target (Yes/No) Mental Capacity Act Level 1 203 233 87% 90% No Deprivation of Liberty Safeguards 203 233 87% 90% No

Qualified nursing staff did not meet the trust training target for either of the training modules relating to the Mental Capacity Act (MCA) or Deprivation of Liberty (DoLS). A breakdown of compliance for Mental Capacity Act (MCA) and Deprivation of Liberty Safeguarding (DoLS) courses at September 2018 for medical staff in maternity is shown below:

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Number of Number of eligible staff trained staff Completion Trust Met Name of course (YTD) (YTD) rate Target (Yes/No) Mental Capacity Act Level 1 31 38 82% 90% No Deprivation of Liberty Safeguards 31 38 82% 90% No

Medical staff did not meet the trust training target for either of the training modules relating to the Mental Capacity Act (MCA) or Deprivation of Liberty (DoLS). Note: The training data for medical staff in maternity incudes some staff who work across both maternity and gynaecology. (Source: Routine Provider Information Request (RPIR) – Statutory and Mandatory Training tab) All staff that we spoke with told us that they had completed recent training on the mental capacity Act and could describe the process of contacting the trust’s mental capacity act team for an assessment and input into best interest decision making if required. Consent forms for women who had undergone caesarean sections detailed the risk and benefits of the procedure and were in line with Department of Health consent to treatment guidelines.

Is the service caring? Compassionate care Staff cared for women with compassion. Feedback from women and their partners confirmed that staff treated them well and with kindness.

Friends and Family test performance Please note that data for November 2017 was not published by NHS England due to data quality concerns.

Friends and family test performance (antenatal), Norfolk and Norwich University Hospitals NHS Foundation Trust

From September 2017 to September 2018 the trust’s maternity Friends and Family Test (antenatal) performance (% recommended) was generally similar to the England average in every month other than February 2018. In the most recent month (September 2018), the trust’s antenatal score was 97%, compared the England average of 95%. Trust data for December 2017 was suppressed as less than five responses were received.

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Friends and family test performance (birth), Norfolk and Norwich University Hospitals NHS Foundation Trust

From September 2017 to September 2018, the trust’s maternity Friends and Family Test (birth) performance (% recommended) was generally similar to the England average. In the most recent month (September 2018), the trust’s birth score was 100%, compared the England average of 96%.

Friends and family test performance (postnatal ward), Norfolk and Norwich University Hospitals NHS Foundation Trust

From September 2017 to September 2018, the trust’s maternity Friends and Family Test (postnatal ward) performance (% recommended) was generally better than the England average. In the most recent month (September 2018), the trust’s postnatal ward score was 97%, compared the England average of 94%.

Friends and family test performance (postnatal community), Norfolk and Norwich University Hospitals NHS Foundation Trust

From September 2017 to September 2018, the trust’s maternity Friends and Family Test (postnatal community) performance (% recommended) was generally similar to the England average. In the most recent month (September 2018), the trust’s postnatal score was 100%, compared the England average of 98%.

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Trust data for February 2018, March 2018, and May 2018 was suppressed as less than five responses were received. (Source: NHS England Friends and Family Test)

CQC Survey of women’s experiences of maternity services 2017 The trust’s performance was similar to other trusts for 17 of the 19 questions in the CQC maternity survey 2017. The trust performed worse than other trusts for the following questions relating to care in hospital after birth: • Looking back, do you feel that the length of your stay in hospital after the birth was appropriate? • Was your discharge from hospital delayed?

Area Question Score RAG Labour and At the very start of your labour, did you feel that 8.3 About the birth you were given appropriate advice and support same when you contacted a midwife or the hospital? During your labour, were you able to move around 8.1 About the and choose the position that made you most same comfortable? If your partner or someone else close to you was 9.7 About the involved in your care during labour and birth, were same they able to be involved as much as they wanted? Did you have skin to skin contact (baby naked, 9.6 About the directly on your chest or tummy) with your baby same shortly after the birth? Staff during Did the staff treating and examining you introduce 9.4 About the labour and themselves? same birth Were you and/or your partner or a companion left 7.9 About the alone by midwives or doctors at a time when it same worried you? If you raised a concern during labour and birth, did 8.7 About the you feel that it was taken seriously? same Thinking about your care during labour and birth, 9.5 About the were you spoken to in a way you could same understand? If attention was needed during the labour and birth 8.8 About the did a member of staff help within a reasonable same amount of time? Thinking about your care during labour and birth, 8.6 About the were you involved enough in decisions about your same care? Thinking about your care during labour and birth, 9.4 About the were you treated with respect and dignity? same Did you have confidence and trust in the staff 8.9 About the caring for you during your labour and birth? same Care in Looking back, do you feel that the length of your 6.2 Worst hospital stay in hospital after the birth was appropriate? performing after the trusts birth Was your discharge from hospital delayed? 3.7 Worst performing trusts

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If attention was needed after the birth did a 7.0 About the member of staff help within a reasonable amount same of time? Thinking about the care you received in hospital 7.7 About the after the birth of your baby, were you given the same information or explanations you needed? Thinking about your stay in hospital, how clean 8.6 About the was the hospital room or ward you were in? same Thinking about the care you received in hospital 8.0 About the after the birth of your baby, were you treated with same kindness and understanding? Was your partner who was involved in your care 7.9 About the able to stay with you as much as they wanted? same

(Source: CQC Survey of Women’s Experiences of Maternity Services 2017) The service was in the process of setting up a rainbow clinic for women who were pregnant again following a previous bereavement. The service’s bereavement midwife was leading the project and was working with national charities to deliver a clinic that provided emotional support and reassurance to these women. The service provided mementos for women who had experienced a still birth or loss of baby. The service provided heart key rings that split so that the baby could be buried with part of the heart and the mother could keep the other part. We observed staff introducing themselves to women and their families, this included, reception staff, midwives, midwifery support workers (MSW) and medical staff. All interactions we observed between women and staff were respectful and understanding. Women and their partners told us that staff were kind and compassionate. All women we spoke with within the service told us that their privacy and dignity was maintained.

Emotional support Staff provided emotional support to women to minimise their distress. The service had employed a specialist bereavement midwife since our previous inspection. The bereavement midwife coordinated care for women and guided families through the formalities that needed to be completed in the event of a miscarriage, stillbirth or baby loss up to the first year of life. The services bereavement midwife could refer women and their partners for counselling sessions. The service had recently set up a bereavement forum for women who had experienced a miscarriage or still birth. The forum’s first meeting was planned to be held the month following our inspection. Midwives and nurses on Cley ward and EPAU had leaflets and information on how to access support services for miscarriage. Leaflets included booklets for options of a burial including at a local woodland with a service held by the trust’s chaplain in order to help women and their partners with the grieving process. Midwifery staff in the service told us that they received a lot of emotional support from their managers when dealing with significant events in the service or personal issues.

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Understanding and involvement of patients and those close to them Staff involved patients and those close to them in decisions about their care and treatment. Women we spoke with told us they had felt involved in the care delivered and had been given time to ask questions to enable them to understand the treatments or care they received. All three partners we spoke with, told us that they had felt involved in the care of the woman and were comfortable asking questions. One partner we spoke with told us that the staff spoke with both parents rather than just the woman which made them feel involved in the decision making. In all areas we observed staff giving explanations in terms that women and their partners could understand. The service provided information to women and received feedback through social media platforms.

Is the service responsive? Service delivery to meet the needs of local people The trust planned and provided services in a way that met the needs of local people. Women accessed maternity services through their GP practice or by using the service’s online booking form and could choose a consultant led birth, a midwifery led birth or a home birth dependent on suitability following a risk assessment. The service had taken part in a recent survey with the independent group ‘maternity voices’. The survey had identified that women felt that the antenatal ward was noisy and could be difficult to sleep on at times. In response to the survey the service had invested in soft-close bins and had ordered eye-masks and ear-plugs to help women staying on the ward have a better experience. The service allowed partners to stay on both the antenatal and postnatal wards following feedback from women using the service. Cley antenatal ward had a leaflet for partners explaining that the service welcomed partners to stay but provided advice on how to ensure that they were respectful to other women using the service. Staff told us that they had some fold-up beds available and riser-recliner chairs for partners to sleep in but told us that these resources were limited. The service provided examples of where they had audited services with the goal of improving women’s experience. The service was in the process of auditing time from induction of labour to being admitted to the delivery suite and also auditing the time it took for women to be scanned and to see a consultant in the antenatal clinic. The service provided a weekly frenectomy clinic for babies with tongue tie as they found that there was a high demand for this service in the local area. Frenectomy is a simple oral surgical procedure that eliminates the presence of a frenum (a muscular attachment) under the tongue. The clinic was managed by an infant feeding specialist and a paediatric surgeon.

Bed Occupancy From April 2017 to September 2018, the bed occupancy levels for maternity at the trust were lower than the England average, with the trust having 48.5% occupancy in Quarter 2 2018/19 compared to the England average of 59.6%.

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The chart below shows the occupancy levels compared to the England average over the period.

(Source: NHS England)

Meeting people’s individual needs The service took account of women’s individual needs. The service worked in partnership with local organisations to ensure care was delivered and coordinated in a way that supported women with complex needs. Comprehensive handheld records assessed and identified the individual needs of women. The service provided women with yellow handheld records which included a section to discuss birth preferences. This was discussed with midwives during antenatal appointments. We saw that the section included preferences on pain relief, positioning and the environment during labour. The trust has three learning disability specialist nurses (two full time and one-part time). The trust had a 'flagging and alert' system for patients with learning disabilities and/or autism spectrum conditions. This alerted the learning disability liaison nursing team whenever somebody with one of those conditions was admitted. Staff were aware of the learning disability team and could demonstrate how they would contact them using the trust’s intranet pages. The service was delivered and coordinated in a way that supported women with complex needs. There were three vulnerable women midwives to support women with mental health concerns, substance abuse issues and domestic abuse. Women could be referred into the vulnerable women’s team at any point during their pregnancy, but were often routinely referred at the booking appointment. The service ran a multidisciplinary vulnerable women’s clinic with the lead consultant for vulnerable women, the vulnerable women’s midwives and support from the community trust’s peri- natal mental health team and a psychiatrist. The service worked alongside the community peri-

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 255 natal mental health team and the community substance misuse service to deliver integrated care plans for these women. Women with complex needs were discussed at the service’s bi-weekly multi-agency meetings which were attended by the vulnerable midwife team, the safeguarding midwife team, the family care team from the neonatal intensive care unit, the trust’s substance abuse liaison nurse, safeguarding leads from the community health visiting team, peri-natal mental health community team from the local mental health trust and a substance abuse nurse from the local service. The service worked in partnership with the local NHS mental health trust to deliver services for women who were experiencing mental health problems during or after pregnancy. The service had been involved in the planning of a new mother and baby unit at another hospital and could refer women to its services. The service had access to translation services through an application stored on electronic tablets. Staff also could telephone the services interpreter service when a tablet was not available. The service had leaflets and posters in different languages displayed in the antenatal area including a poster which explained reduced fetal movements in multiple languages. Women who were experiencing a miscarriage up to 22 weeks and six days of pregnancy were placed on Cley ward which was the service’s gynaecology ward. Staff on Cley ward told us that they always ensured that women experiencing miscarriage were cared for in a side room to protect their privacy and dignity. We were concerned that this was not the most appropriate area for women to be when miscarrying at a later stage into a miscarriage. Staff on the ward told us that they did not feel they always had the necessary skills to care for these women at later stages of miscarriage and that they felt these women should be cared for on the delivery suite. Nursing staff told us that they found it difficult to nurse these women as they didn’t have any specific obstetric training and relied on the midwives on the antenatal section on the ward and escalating to the obstetric consultants. The service leads were aware of this as an issue and had recently conducted an audit into the number of women miscarrying on Cley at a later stage to determine if the service should change their guidelines. The service had worked alongside a non-profit organisation to develop short movie clips about post-natal depression to educate women and signpost to support organisations. The service had also created films on what to expect when having a caesarean section at the trust to ensure women understood the process and felt at ease. The service offered both medical and a mechanical induction of labour. The benefit of mechanical induction for low risk women was that they could return home after having the procedure and await signs of labour or return for reassessment the next day. The bereavement midwife provided women who had experienced a stillbirth or baby loss with a saying goodbye leaflet that detailed the support options available to her and her partner. Cold cots were available to extend the time families could spend with their baby including allowing babies to be taken home using the cold cots. Women were supported to make special memories for the baby they had lost. The service did not have a bereavement suite but had secured funding and planned to convert one of the rooms on the delivery suite into a bereavement suite complete with a separate entrance and frosted glass to provide women with dignity and privacy. The plans also included a kitchenette and seating area to allow the women and their families to feel comfortable. The service created a quiet room in the antenatal area that could be used to deliver bad news to expectant mothers in a sensitive environment.

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The service had five transitional care beds on the postnatal ward to support mum and baby staying together.

Access and flow People could access the service when they needed it. Waiting times were audited and processes changed to improve women’s experience. However, the service was not following national guidance for tracking women who had booked into the service. The National Institute of Clinical Excellence guidance [CG62] recommends that women are booked into the service by 10 weeks. However, the service’s target for booking women was by week 12 of pregnancy plus six days. The service reported on this target on their maternity dashboard which showed that from April to September 2018 the service met this target for 91.6% of women. The service was not tracking and reporting on the number of women booked in within the 10 week standard. We requested that the trust provide us with the percentage of women booked into the service within ten weeks but this was not provided to us. Women were booked into the service by community midwives in GP surgeries in the local area. Women could self-refer into the service using the trust’s online referral form which meant that they didn’t need to wait to be referred by their GP. The information that women provided during their online referral automatically populated into the service’s records management system for booking to enable a more efficient booking process. The fetal medicine clinics were operated by three consultants and managed by a lead specialist midwife. The clinics offered diagnosis and treatment for complications that may arise in unborn babies. The delivery suite, pregnancy assessment and triage unit were accessible 24 hours a day. Women who were assessed as being in labour were directed immediately to the delivery suite. Community midwives provided an on-call service for those women booked for a home birth. Staff implemented the escalation policy when there were unexpected shortages of staff. Managers and staff could explain these processes. Managers were on call off site out of hours to provide advice to staff when the service was busy. The delivery suite had closed twice between January 2018 and January 2019. Staff we spoke with could explain the escalation process for closure of the unit and show us where the guidelines for unit closure were on the trust’s intranet. Women who missed antenatal appointments were followed up by the antenatal team based at the hospital who would telephone the woman to book another appointment. The service monitored cancellations of elective caesareans and the reasoning for the cancellation. We saw that between April 2017 and March 2018 that 13 elective caesareans had been cancelled out of 742 which was a rate of 1.7%. Three were cancelled due to the woman being transferred, one was cancelled because a list overran, ten were cancelled as they were no longer necessary and two for reasons listed as ‘other’. The service was working to improve the time from induction of labour was started to the birth. This was because the service’s time from induction to transfer to labour ward for artificial rupture of membranes was on average 40 hours. The service had recently expanded its criteria for the outpatient induction pathway for low risk women to decrease the number of women admitted as inpatients for induction of labour and to allow for greater choice for women using the service. The service had recently started a trial of women being discharged home by the midwife on the postnatal ward, Blakeney. This meant that women who suitable in line with the service’s criteria 20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 257 could be discharged to go home by a midwife without having to be seen by a doctor which reduced the delays in discharge. The service recorded the transfer of women to another unit on their maternity dashboard. We saw that there had been 10 diverts from April to September 2018. The service experienced high levels of scanning referrals and had limited capacity within the department. In order to address the capacity concerns the service expanded the scanning consultations clinics and was currently training a midwife sonographer to increase capacity.

Learning from complaints and concerns Promoting the complaints process was not embedded practice for staff within the service. The service investigated complaints, learned lessons from the results, and shared these with all staff.

Summary of complaints From October 2017 to October 2018 there were 43 complaints about maternity. The trust took an average of 25 days to investigate and close complaints, and 60.5% of the complaints were closed within 25 days. This is in line with their complaints policy, which states that more than 50% of complaints should be closed within 25 days. A table of complaint subjects can be found below. Number of Percentage of Core service complaints total complaints Communications 13 30.2% Clinical Treatment - Obstetrics & Gynaecology 11 25.6% Patient Care including Nutrition/Hydration 5 11.6% Privacy, Dignity and Wellbeing 4 9.3% Admission, Discharge and Transfers 3 7.0% Waiting Times 2 4.7% Facilities 2 4.7% Values and Behaviours (Staff) 1 2.3% Clinical Treatment - Anaesthetics 1 2.3% Consent 1 2.3% Total 43 100.0% (Source: Routine Provider Information Request (RPIR) – Complaints tab)

Number of compliments made to the trust From October 2017 to September 2018 there were 32 compliments within maternity. A breakdown by ward can be found below. Percentage of Number of Ward name/area total compliments compliments Delivery Suite 11 34.4% Blakeney Ward 6 18.8% Antenatal Ultrasound 4 12.5% Cley Obstetrics 4 12.5% 20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 258

Midwifery Led Birthing Unit 3 9.4% Early Pregnancy Assessment Unit 2 6.3% Community Midwifery 1 3.1% Antenatal 1 3.1% Total 32 100.0% (Source: Routine Provider Information Request (RPIR) – Compliments tab) We were not assured that people who used the service knew how to raise complaints and staff within the service did not promote the complaints process to women wanting to make a complaint. The service had complaint leaflets at the midwives’ station on the postnatal ward and on the reception desks at the antenatal and scanning clinics. However, we spoke with two women who told us that they were unhappy with the service they had received but were not aware of how to make a complaint. One woman we spoke with told us that she had raised a concern about a member of staff to another member of staff but was not given further information on how to make a formal complaint. All staff we spoke with were aware of the process for women to make complaints however promoting the complaints process was not embedded practice. Staff could provide examples where services had been improved as the result of complaints including reducing waiting times and patient experience by trialling new induction of labour pathways. We saw that complaints were discussed as part of the maternity directorate meetings.

Is the service well-led? Leadership Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care. Maternity was within the Women’s and Children’s Services Division and the management structure included the gynaecology speciality. The service was led by a chief of division who also held the role of head of maternity. The chief of division was supported by the chief of service who was a consultant obstetrician, a deputy head of midwifery and a risk and governance manager. Staff consistently told us that they received good support from their managers within the service at all levels. One member of staff provided an example of their manager being supportive and compassionate when they had been off on long-term sick from the service. Staff were unanimously positive when speaking about the senior leaders in the service and told us that they were trusted and respected. The executive team were visible in the organisation. We saw that the service had posters on the wards explaining who the executive team were and how to contact them. Staff told us that the chief executive invited staff to coffee mornings and that members of the executive team were present at the daily serious untoward incident meetings held in the trust. The trust’s chief nurse was the maternity safety champion for the trust which allowed a board level staff member to escalate locally identified issues. The service’s maternity safety champion arrangements were used as a reference for good practice in NHS Improvements ‘A guide to support maternity safety champions’. Staff we spoke with told us that they were concerned about succession planning within the service as a sizeable percentage of the workforce were due to retire in the next few years. We spoke with

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 259 the senior leadership team who spoke about their succession plan which included upskilling staff in the directorate and enabling staff to shadow leads within the service. The service had leadership programmes for band seven midwives and the service offered secondments to roles to ensure that there was opportunity for career development within the service. The service had a structure in place to support midwives with supervision. The service had three sessional professional midwifery advocates (PMA) who offered supervision and support to staff through a weekly session to replace the role of supervisor of midwives. The service had plans to increase the number of PMA’s and had recently appointed a full-time PMA with funding secured to train a further six midwives to be sessional PMA’s. The head of midwifery had access to the board and strong working links with the chief nurse and medical director for the trust. The chief nurse had attended the divisional board meeting and chaired the safety sub-board meeting which the service reported into. The service had a robust system in place to report qualifying incidents under the NHS Resolutions Early Notification scheme. The scheme requires trusts to report all maternity incidents that have led to severe brain injury. The trust’s legal department used the early notification report form and referred the incident within 14 days of the incident. The maternity risk team had oversight of this to ensure that cases were not missed.

Vision and strategy The trust had a vision for what it wanted to achieve developed with involvement from staff, patients, and key groups representing the local community. However, progress against the delivery of the strategy was not regularly monitored and reviewed. Leaders within the service told us that they had a strategy that was created in 2017 but was not a working document that received regular reviews to report on progress. We reviewed the strategy which included the service’s commitment to work in partnership with local stakeholders and to implement national guidance. We saw that the service had met some of the targets in the strategy and that it aligned with the quality improvement programmes the service was undertaking. We raised with senior leaders in the service about the lack of regular review of the strategy and the service leads told us that it would be added to the services clinical governance meeting as a standing agenda item. The service’s future plans linked with the local health economy and the service demonstrated strong links with services in the wider economy through the joint working at the Local Maternity System (LMS) which was part of the sustainability and transformation programme involving other local trusts and local authorities. The LMS had a sustainability plan which the trust was engaged with and had responsibility in-part for delivering. The plan included references to national strategy and policy such as increasing the number of births in low risk settings. The service demonstrated strong joint working and future planning with the local mental health trust in submitting a bid for a local mother and baby unit which had just opened in the local area.

Culture Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.

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All staff we spoke with told us that they enjoyed working for the trust and that there was a positive culture within the service. Staff told us that they were proud to work for the service and felt that the service prioritised the care and needs of the women they looked after. We observed good multidisciplinary working between midwifery and medical teams and it was clear that there were strong working relationships, and respect for team members skills, from junior staff through to the most senior leaders. The service had processes in place to reward staff for their hard work. The service leads told us that they had an above and beyond award in which anyone can nominate a staff member for. The service had recently held a thank you week for their midwifery care assistants which included a thank you high tea. Community staff told us that they felt part of the overall maternity service and felt respected and valued in their roles. All staff we spoke with told us that they would feel comfortable raising any concerns they had with their immediate line managers. We saw that 97% of staff felt they were able to report concerns about unsafe clinical practice in the staff survey. The 2017 staff survey had mixed results. Some questions were answered with very positive scores, such as 84% of staff said that training, learning and development had helped them do their job more effectively and 90% of staff were satisfied with the support they received from colleagues. However, only 29% of staff said that communication between senior management and staff is effective and only 26% of staff felt that senior managers act on staff feedback. We saw that the Trust had created a detailed action plan in response to the survey which included holding regular team meetings to improve communication from the senior team and recruiting a patient experience manager to improve the trusts responsiveness to feedback. The service had positive results from the General Medical Council’s trainee survey which found that junior doctors had an overall satisfaction rate of 77.9%. The service were open and honest when things went wrong. Staff had a strong understanding of the duty of candour and we viewed three letters where the duty of candour had been exercised and found them to be appropriate.

Governance We saw evidence of effective structures, systems and processes to support the delivery of high quality care. The service had structures in place to report incidents, identify learning and share learning throughout the organisation. However, the service did not have the governance structures in place to monitor consumable equipment and medicines in the community. We checked one community midwife’s car and found out of date consumable equipment, expired medicines and inappropriate storage of medical gases. Midwifery staff told us that there was not a system in place to ensure that equipment and medicines were in date and that medical gases were stored appropriately. We were not assured that senior leaders within the service had oversight of these issues. The service monitored their performance through monthly clinical governance meetings. We reviewed the minutes of the last three meetings and saw that the meetings discussed the services’ risks, incidents, audits, complaints and national guidance. The service looked at their risks in detail at the divisional risk management meeting.

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The service had monthly maternity directorate meetings. We reviewed the minutes of the last three meetings and saw that the meetings discussed monthly reports from matrons, service development proposals, complaints, incidents, risks, national guidance, workforce, and finance reporting. The core membership of the meetings included consultants, matrons, the head of midwifery, finance business partner and HR business partner. The clinical governance meeting, risk management and maternity directorate meeting reported to the trust board meetings including the clinical safety sub-board and the governance and business board. The division had to prepare reports for these boards which included high level information on risks, incidents and complaints. Staff told us that the monthly governance meeting was well attended by both medical and midwifery staff. We reviewed three sets of meeting minutes which confirmed this. The service could demonstrate compliance with all four elements of the Saving Babies’ Lives care bundle with the following compliance rates: 75% for reducing smoking in pregnancy, 100% for risk assessment for surveillance for fetal growth restriction, 100% raising awareness of reduced fetal movements and 100% effective fetal monitoring during labour. Saving Babies’ Lives is designed to tackle stillbirth and early neonatal death. It brings together four elements of care that are recognised as evidence-based and/or best practice.

Management of risk, issues and performance Not all risks we identified on inspection featured on the risk register and we were concerned that there was a lack of oversight for medicines, equipment and lone working in the community setting. Some of the issues that we had identified on our previous inspection remained unresolved. However, the service had developed an extensive programme of quality improvement which was used to improve the quality of services in certain areas. The service had not rectified all the issues we identified on our previous inspection. On our previous inspection in April 2017 we told the trust that it must ensure staff complete mandatory training to a level appropriate to their job role. On this inspection we found that the service’s medical staff were not trained to an appropriate level of children’s safeguarding training in accordance with national guidance. In 2017 we told the trust that it must ensure that resuscitation equipment is checked in accordance with trust policy. On this inspection we found that there were gaps in the recording of resuscitation equipment checks. In 2017 we told the trust they must ensure patient records are stored securely. On this inspection we saw that patient records were still stored in unlocked cabinets on the wards. In 2017 we also told the trust that staff must record the medication refrigeration temperatures to ensure the safe storage of medication. On this inspection we found that medication refrigeration temperatures were not consistently recorded. We were not assured that these risks were being managed appropriately by the service. The service had a lead risk midwife who chaired the service’s weekly risk meetings in which they discussed all post-partum haemorrhages over two litres, any neonatal deaths and any cases where a baby had to be cooled. The meetings would discuss any areas of concern that staff identified and escalate the concerns onto the risk register for oversight from senior staff. The service held weekly risk meetings with the service’s risk midwife, these allowed staff the opportunity to report any identified risks. The weekly risk meetings reported into the monthly divisional risk meeting in which the service would discuss items on their risk register and any new

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 262 risks raised at the service’s weekly risk meetings. We reviewed the risk register for the service and saw that risks identified by the service included non-compliance with National Institute of Clinical Excellence guidance, staffing capacity of the second theatre out of hours and a backlog of incidents to be investigated. We saw that all risks had mitigating actions, an assigned person responsible and that the service had put in place plans to remove the risks entirely. Whilst most of the risks we identified on inspection featured on the risk register, risks such as the lack of equipment checking in the community and daily checking of medicines fridges did not. The service’s arrangements for lone working in the community were not embedded. Staff told us that there was a lone working policy and that they had personal alarms but they often didn’t take them out with them. Staff told us that they did not have anyway of logging if they were safe at the end of visits. The service had a maternity dashboard which it used to report on outcomes in the service such as the percentage of caesarean sections, one to one care in labour and breastfeeding rates. The dashboard was discussed in clinical governance meetings, divisional meetings and reported to the trust’s clinical safety sub board and featured in the trust’s board papers. Outcomes on the maternity dashboard were not clearly colour coded meaning that it was difficult to identify where the service had not met their targets. Service leads had told us that they were aware that this was an issue and were working on a new dashboard and wanted to set meaningful targets for the dashboard. The service had looked at dashboards from other trusts to benchmark where their targets should be. The service contributed to the Local Maternity System (LMS) dashboard which compared the trust with two other trusts in the local area. We viewed the LMS dashboard and saw that the service compared favourably with local trusts in terms of smoking rates and the number of home births. The service had an extensive programme of quality improvement (QI) being undertaken. There were 12 QI projects being undertaken in the women and children’s division including projects to improve avoidable admissions to the neonatal unit, a project on induction of labour pathways, reducing smoking and a thermal care bundle (TCB) project. The TCB project aimed to reduce hypothermia in new-born infants. The service had an online platform to review progress on the projects and to update any actions. There was a systematic programme of clinical and internal audit to monitor quality and systems to identify where action should be taken.

Information management The trust collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards. After our previous inspection we identified that community midwives did not have access adequate access to information technology. We identified improvements on this inspection which included that community midwives had been provided with computers with access to the trust’s guidelines and the service’s record management system. The records management system was currently only available through wireless internet connectivity and community midwives that we spoke with told us that they often experienced connectivity issues. The service’s leadership team were aware of the issue and were in the process of obtaining an offline version of the records management system.

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The service employed an IT specialist midwife to support staff with the electronic records system and other programmes.

Engagement The trust engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively. The service utilised social media to engage with women using the service and to collect feedback; social media groups included a page for women in pregnancy and a page for infant feeding. The trust had an active maternity voices partnership (MVP), an advisory group made up of professionals and parents working in partnership, including staff, representatives of clinical commissioning groups (CCGs), parents who have used the services in the last five years and other community groups such as National Childbirth Trust (NCT). Staff within the service could provide examples of when leaders within the service had sought their feedback. Staff could provide examples of two different consultations that had taken place with staff regarding shift patterns and spoke positively about the changes made as a result of the consultations. Staff on Blakeney ward told us that there weren’t regular team meetings as attendance had been an issue, but they communicated through a group conversation on a mobile application. We reviewed the last three team meeting minutes from the delivery suite, midwifery led unit and community meetings and saw that meetings shared information with staff and provided an opportunity for them to raise any concerns. Staff could provide examples of where they had raised concerns with managers in the service and positive action had been taken to address the issues. One example was the capacity within the sonography team, in order to lighten the load, the service employed an operations manager at the request of the sonography team.

Learning, continuous improvement and innovation The trust was committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation. The service had included human factors training as part of their PROMPT programme. The training was received well by staff and had been picked up by the Royal College of Obstetricians and Gynaecologists and delivered nationally. The service had introduced a continuous carer pathway so that women could have the same midwife involved in the antenatal, intra-partum and post-partum care, when the woman was booked for an elective caesarean. The named midwife would provide antenatal care, be present in theatre at the caesarean section and be responsible for the post-natal care. This improved the consistency of the named midwife and gave women a choice in the support they received.

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Services for children and young people

Facts and data about this service Paediatric medical and surgical services are provided across dedicated paediatric outpatient clinics and also a number of wards at the Jenny Lind Children’s Hospital: • Buxton ward (33 beds including four high dependency) • Children's assessment unit (11 beds including one treatment room for the most sick children) • Children’s day ward (four beds) • Neonatal unit level three (42 cots) Sub speciality provision with specialist nurse input is provided for paediatric gastroenterology, rheumatology, allergy, respiratory, diabetes and endocrinology, dermatology, RLF (tongue tie), orthopaedics and ear nose and throat (ENT). The children’s day procedure unit (DPU) provides six beds for children's surgery, and is hosted by the surgical division. Paediatric surgery is provided for upper and lower gastrointestinal, thoracic, ear nose and throat (ENT), tongue tie (RLF), orthopaedic and urology. Emergency assessment and treatment provision is provided through a 24/7 children’s assessment unit which can accept attendance/ referrals from GPs, ED and ambulances. This trust also provides regional level 3 intensive care for neonates, as well as a 7-day outreach service. (Source: Routine Trust Provider Information Request (RPIR) – Context acute) The trust had 9,183 spells from August 2017 to July 2018. Emergency spells accounted for 75% (6,930 spells), 21% (1,952 spells) were day case spells, and the remaining 3% (301 spells) were elective.

Percentage of spells in children’s services by type of appointment and site, from August 2017 to July 2018, Norfolk and Norwich University Hospitals NHS Foundation Trust.

Total number of children’s spells by Site, Norfolk and Norwich University Hospitals NHS Foundation Trust.

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Site name Total spells Norfolk and Norwich University Hospital 9,183 This trust 9,183 England total 1,125,448 (Source: Hospital Episode Statistics)

Is the service safe? By safe, we mean people are protected from abuse* and avoidable harm. *Abuse can be physical, sexual, mental or psychological, financial, neglect, institutional or discriminatory abuse. Mandatory training The service provided mandatory training in key skills to all staff, however we were not assured that there was consistent management of mandatory training compliance across the service.

Mandatory training completion rates The trust set a target of 90% for completion of mandatory training. This target was 5% below the trust target at our last inspection. A breakdown of compliance for mandatory training courses at September 2018 at trust level for qualified nursing staff in children’s services is shown below:

Number Number of of staff eligible trained staff Completion Trust Met Name of course (YTD) (YTD) rate Target (Yes/No) Fire Safety 182 189 96.3% 90% Yes Health and Safety (Slips, Trips and Falls) 181 189 95.8% 90% Yes Medicine management training 168 178 94.4% 90% Yes Manual Handling - People 83 88 94.3% 90% Yes Adult Basic Life Support 172 185 93.0% 90% Yes Resuscitation 173 187 92.5% 90% Yes Manual Handling - Object 93 101 92.1% 90% Yes Equality and Diversity 168 189 88.9% 90% No Infection Prevention (Level 2) 164 189 86.8% 90% No Blood Transfusion 152 177 85.9% 90% No Information Governance 160 189 84.7% 90% No Clinical Record Keeping 155 189 82.0% 90% No Venous Thromboembolism 1 2 50.0% 90% No

In children’s services the 90% target was met for seven of the 13 mandatory training modules for which qualified nursing staff were eligible. A breakdown of compliance for mandatory training courses at September 2018 at trust level for medical staff in children’s services is shown below:

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Number Number of of staff eligible trained staff Completion Trust Met Name of course (YTD) (YTD) rate Target (Yes/No) Health and Safety (Slips, Trips and Falls) 73 75 97% 90% Yes Blood Transfusion 68 75 91% 90% Yes Medicine management training 67 74 91% 90% Yes Infection Prevention (Level 3) 63 72 88% 90% No Clinical Record Keeping 65 75 87% 90% No Fire Safety 62 75 83% 90% No Manual Handling - Object 58 75 77% 90% No Venous Thromboembolism 51 67 76% 90% No Equality and Diversity 52 75 69% 90% No Resuscitation 42 70 60% 90% No Information Governance 40 75 53% 90% No Adult Basic Life Support 2 6 33% 90% No

In children’s services the 90% target was met for three of the 12 mandatory training modules for which medical staff were eligible. (Source: Routine Provider Information Request (RPIR) – Training tab) At the time of our inspection the matron told us that the most up to date mandatory training compliance figures were 100% in the Jenny Lind Outpatients Department, 100% on the day ward, 98% on the children’s assessment unit (CAU) and 80% on Buxton ward. The manager of the neonatal unit (NNU) told us that mandatory training compliance on the NNU was 70%. Reasons for compliance levels below the target of 90% were a number of return to work nurses had not yet completed their mandatory training, and some staff were on long term leave. At our last inspection, we found that mandatory training compliance was below the trust target of 95%. There was a trust-wide improvement strategy for sepsis training, protocols and procedures. A training programme was being led by an intensive care consultant and a sepsis nurse and case studies were being shared at directorate governance boards to share learning. Staff we spoke with understood the sepsis pathway. Data we requested showed that 88.6% of staff working in the service had received practical sepsis training. This was an improvement from our last inspection where we were not assured that clinical staff were receiving training in sepsis protocols and procedures. We requested data to show us how many nurses providing care to children in adult areas were trained safeguarding children level three, and paediatric life support training. The trust provided data showing admission to seven clinical locations. We did not include three of these locations in our consideration of the data as they were clinically appropriate for those admissions, such as maternity, day surgery and critical care. Of the remaining four locations, the trust did not provide any training data. We were not assured that staff caring for children in adult areas were trained appropriately in safeguarding and paediatric life support. At our last inspection we said that the trust should ensure that staff caring for children in non-paediatric areas have appropriate training to do so.

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86.5 percent of staff working across the service had received new born and paediatric basic life support. 73 percent of staff working on the NNU were trained in neonatal life support. 84.1 percent of main theatres recovery staff had paediatric basic life support training. 82 percent of day surgery unit staff had paediatric life support training. All nursing staff on Buxton ward were required to have completed European Paediatric Advanced Life Support (EPLS) training Learning Disabilities (LD) training was delivered to staff in several ways such as Corporate Induction, Nursing Assistant induction and Bespoke sessions as requested by departments, or identified by the LD team. Numbers of staff attending this training had not been captured. Therefore, we were not assured that staff had adequate understanding of how to provide the most appropriate care to children with LD’s. The trust’s Mental Health Liaison Team (MHLT) had delivered training sessions covering numerous elements of mental health awareness. At the time of our inspection the trust was not able to provide us with data about the numbers of staff attending these training sessions. Therefore, we were not assured that staff had adequate knowledge of mental health awareness. A trust wide mental health improvement plan was in place and was due to commence in April 2019.

Safeguarding Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it, however we were not assured that there was a consistent overview of safeguarding training compliance

Safeguarding training completion rates The trust set a target of 90% for completion of safeguarding training. A breakdown of compliance for safeguarding training courses at September 2018 at trust level for qualified nursing staff in children’s services is shown below:

Number of Number of eligible staff trained staff Completion Trust Met Name of course (YTD) (YTD) rate Target (Yes/No) Safeguarding Adults (Level 2) 179 189 95% 90% Yes PREVENT - Level 3 161 185 87% 90% No Safeguarding Children (Level 3) 153 189 81% 90% No

In children’s services the 90% target was met for one of the three safeguarding training modules for which qualified nursing staff were eligible. A breakdown of compliance for safeguarding training courses at September 2018 at trust level for medical staff in children’s services is shown below:

Number of Number staff trained of Completion Trust Met Name of course (YTD) eligible rate Target (Yes/No)

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staff (YTD) Safeguarding Children (Level 3) 69 74 93% 90% Yes Safeguarding Adults (Level 2) 50 75 67% 90% No PREVENT - Level 3 41 67 61% 90% No Safeguarding Children (Level 2) 0 1 0% 90% No

In children’s services the 90% target was met for one of the four safeguarding training modules for which medical staff were eligible. (Source: Routine Provider Information Request (RPIR) – Training tab) In an interview with the service management, we were told that safeguarding level three training compliance across the division was 92.5%. However, the head of safeguarding told us that the same level training compliance was 82.2%. The safeguarding team for children consisted of the head of safeguarding, who was also the named nurse, and a deputy for safeguarding children. The trust had a named doctor for safeguarding children. Level four safeguarding training compliance for the safeguarding team was at 60%. This percentage was affected by the small numbers of the team. This meant that regional conferences and meetings were attended and training was provided by NHS England. The head of safeguarding had oversight of learning from the community as well as in the trust. One example of a sudden unexpected death in infants and childhood case was given, where a multidisciplinary meeting took place and a rapid response team conducted home visits. Non-compliance with training was followed up by emailing individuals to remind them to book their training, and copying their managers in. There was a plan to roll out joint level three child and adult training in May 219, which would be a full day of training. However, this was not in place at the time of our inspection. At our last inspection we told the trust to ensure that staff caring for children in non-paediatric areas have appropriate safeguarding training. We requested this data for this inspection but the trust did not provide it. We asked senior nursing staff in main theatres who told us that staff looking after children and young people were 97% compliant with level three safeguarding children training in December 2018. Child sexual exploitation was included in the safeguarding policy and training. There was however no reference to female genital mutilation in the safeguarding children policy. Training included face to face sessions and scenario enactment. An abduction policy was in place and in date. A practice simulation was successfully undertaken to test the policy. There was a safeguarding supervision policy available for staff on the intranet. Nurses received one to one or group supervision. The safeguarding team received supervision from peers in other organisations, with access to this being every two months. There was a policy in place for dealing with VIP’s, celebrities and volunteers in the trust. Compliance with this policy was reported to the clinical commissioning group. A child protection information system had been implemented. This was a secure information sharing system that allowed multiple agencies to better protect vulnerable children. This was working well for the trust as well as partner organisations and included female genital mutilation.

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External assurances of the trust’s safeguarding children processes were gained through quarterly meetings with the local clinical commissioning group. Internal assurances were gained by safeguarding being a standing agenda item on the clinical safety sub group meetings, safeguarding meetings every two months with senior managers in attendance, and daily serious incident groups where moderate and high-risk incidents that day were discussed. The head of safeguarding told us there was a good relationship with the clinical commissioning groups and local safeguarding boards. Urgent and acute child protection medicals were carried out in the children’s outpatient’s department (OPD). Staff in the OPD could explain the process when children did not attend their appointments. This included when and how notifications were made to GP’s and the safeguarding team if appropriate. Chaperoning posters were seen throughout the OPD to ensure that children, young people and their families were aware of their right to a chaperone when being clinically examined. Safeguarding paperwork and concerns were recording in patient notes on purple coloured paperwork, making it easy for all staff to be aware of any concerns.

Cleanliness, infection control and hygiene The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.

CQC Children and Young People’s Survey 2016 In the CQC Children and Young People’s Survey 2016 the trust scored 9.0 out of ten for the question ‘How clean do you think the hospital room or ward was that your child was in?’ This was about the same as other trusts. (Source: CQC Children and Young People’s Survey 2016, RCPCH) The service had infection prevention and control link nurses throughout its clinical locations. This meant that infection control audits and learning was shared by each unit’s link nurses to their colleagues. Information was also shared by the infection control ‘owl’ newsletter. Infection control audit result posters were displayed in all clinical areas throughout the service. All services displayed their most recent results for hand hygiene, uniform and commode audits. One hundred percent audits were achieved consistently. We saw ‘I Am Clean’ stickers on equipment throughout the service. These stickers indicated the last time a piece of equipment had been cleaned. All equipment checked had been cleaned ready for its next use. CAU had two side rooms for patients who were infectious. There were plans in place for the unit to gain a point of care testing kit for influenza although this was not in place at the time of our inspection. We did not see any evidence of cross infection risk from cohort nursing in the open plan layout of CAU, as we found on our last inspection where cohort nursing was taking place in open bays with non-infectious children. Cohort nursing, where infectious patients are treated together in one area away from other patients, was practiced on Buxton ward appropriately. We saw staff taking 20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 270 appropriate measures to prevent cross infection, including wearing appropriate personal protective equipment such as aprons and gloves, and preventing people from entering the bay if they did not need to be in there. Ward attenders on the neonatal unit (NNU) from maternity were accommodated in a dedicated assessment room. This reduced the risk of cross infection for babies admitted to the NNU. Sharps bins we saw around the service were not filled beyond their limits and we saw bins with labelling completed throughout the service. Play equipment in the recreation rooms was cleaned by the play specialists. We saw hand hygiene information displayed throughout the service, and we saw staff washing their hands and using the available alcohol gel dispensers.

Environment and equipment The service had suitable premises and equipment and looked after the majority of them well. The service was secure across all clinical areas. Key pads, card swipe and buzzer entry systems were used throughout to ensure that only authorised people could enter clinical areas. We found resuscitation trolleys to be tamper proof throughout the service. We found resuscitation trolley checks and defibrillator checks to be inconsistent across the service. We checked dates between November 2018 and January 2019, where available. Checks of resuscitation trolleys were consistently achieved in some clinical areas such as NNU and not in others, such as CAU where we found 15 daily checks not done for the period November 2018to January 2019. We found the same issue on our last inspection. This meant that we were not assured that emergency equipment was in working order and ready for use. Checks of the resuscitation trolleys from November 2018 revealed a service wide absence of a certain size endotracheal tube. Endotracheal tubes are inserted through the patient’s mouth into their trachea and then attached to a ventilator to help them breathe. They come in different sizes for different sized patients. We saw evidence in some clinical areas of this being escalated to the resuscitation lead who was communicating with the manufacturer regarding the supply. We did not see this noted on the service risk register. Defibrillators were not consistently checked every day. We looked at the documentation for defibrillator checks for the month prior to our inspection. Where a full month’s checks were not available for us to see, we looked at the available information. We reviewed information for day surgery recovery, main theatres recovery, Buxton ward, and the children’s assessment unit. We found one day missing in day surgery recovery, 12 days missing on Buxton ward, and two days missing on CAU. This issue was identified on our previous inspection in 2017. This meant that we were not assured that the service had functional defibrillators available for use in emergencies. An electronic checking system had been introduced to some of the service, where emergency equipment checks were logged electronically by the scanning of a code. If checks had not been completed by a certain time then the scanning system flagged this with a manager. If the code had not been scanned again after checking, by mid-afternoon then the service management were notified so they could address the issue. We saw different coloured waste bags, labelled bins and sharp bins for different types of waste, such as general waste and clinical waste such as swabs and dressings.

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We checked consumables at random across the service. Out of 44 consumables checked in total, the majority (42) were within their expiry dates. We checked equipment at random across the whole service. All 20 items we checked were within date for electrical safety checks and servicing. The electronic engineering department kept a log of equipment on the NNU, including its servicing and electronic safety testing dates. There was an equipment link nurse on the NNU as there were over 600 pieces of equipment on the unit. The clinical environments on Buxton ward and NNU were cluttered. This was due to a lack of storage space. Pushchairs, monitoring equipment, high chairs, incubators and cots were stored on the wards corridors. There were plans to convert an unused bathroom into a storage room on Buxton ward but this was still in the planning phase at the time of our inspection. There was a separate recovery area for children in main theatres. Children were transported safely from theatre recovery back to Buxton ward. Age and size appropriate portable suction devices were taken with the child, along with an ambu-bag which contained manual resuscitators with different size masks, on the journey back to the ward. The service had plans to change one bay on Buxton ward to a high dependency bay in the summer of 2019. This would allow HDU nurses to work together and meant that a HDU bed would be gained. The existing two HDU bays would become rooms for children with complex needs and would include specific equipment such as hoists. The ward manager had put the plans to the Board and was awaiting a response at the time of our inspection. There was a significant distance between the emergency department (ED) and CAU, the day ward and Buxton ward. To reduce the risk of transferring acutely unwell children between locations, CAU nurses would assist in ED if there were not enough paediatric nurses. Any nurses assisting would have experience of acute clinical environments and would only work within the limitations of their roles, for example, they would not treat any trauma patients. The senior matron for paediatrics and a patient flow team was in place to ensure patient flow was running smoothly. There was also a consultant rotation via ED. This issue had been on the service’s risk register since our last inspection in 2017.

Assessing and responding to patient risk Staff completed and updated risk assessments for each patient. They kept clear records and asked for support when necessary.

CQC Children and Young People’s Survey 2016 In the CQC Children and Young People’s Survey 2016 the trust scored 7.1 out of ten for the question ‘Were the different members of staff caring for and treating your child aware of their medical history?’ This was worse than other trusts. In the CQC Children and Young People’s Survey 2016 the trust scored 9.4 out of ten for the question ‘Were you given enough information about how your child should use the medicine(s) (e.g. when to take it, or whether it should be taken with food)?’ This was about the same as other trusts. (Source: CQC Children and Young People’s Survey 2016, RCPCH)

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The service had access to the local child and adolescent mental health service which enabled children who were experiencing acute mental health problems to receive appropriate and timely care. The service ensured that every shift had a member of staff with advanced paediatric life support training on duty. Escalation processes were established for poorly children and for children requiring transfer. There was an escalation and transfer policy in place for children requiring escalation within the trust, and transfer to tertiary hospitals. This was supported by a ‘transfer folder’ which included a rapid handover document checklist, key contacts, telephone pathways and information for parents such as maps. Early warning scoring systems are guides used by clinical staff to determine the degree of illness of a patient. It is based on giving set scores for vital signs such as respiration rate, oxygen saturations, temperature, and heart rate. The scoring system gives staff a numerical indication of when a patient is deteriorating and when to escalate their care to a more senior member of staff. Children’s early warning score (CEWS) completion was audited. However, staff were unable to tell us any audit results, who the audits went to for review, or what any learning from these audits may be. We reviewed CEWS audit data for April 2018 to December 2018. Audit performance was presented in a ‘red, amber, green’ rating system. Performance at 100-90% was green, 89-80% was amber and 79% and below was red. Throughout this period, scores across the service were consistently green for accurate observation scoring. For the same period however, Buxton ward averaged at 78%, or red, for completeness of those observations. The overall service averaged at 65%, or red, for the frequency of observations meeting national guidelines. Buxton ward averaged 81% and CAU averaged 72%, or red, for documented evidence of nursing review requests. Whilst Buxton ward consistently achieved 100% or green for documented evidence of medical review requested, CAU averaged 78%, or red, for the same period. The trust acknowledged this in their audit report, and aimed to take part in a national audit around early warning scores with a view to implementing an updated CEWS or paediatric early warning scoring system. However, there was no clarity around how specific issues identified for improvement would be achieved. This means that we were not assured that CEWS were consistently performed to completion, that nurse and medical reviews were consistently sought, or that observations were being performed at the right frequency. The emergency call bell system on CAU could not always be heard throughout the unit. This had been actioned and the work to improve this was set for April 2019. To mitigate the risk of a call bell being unheard, a temporary bell had been installed at the nursing station. When a staff member became aware that a call bell was pressed, they would manually ring the temporary bell which rung throughout the unit. This risk had been entered on to the service risk register and was being managed with oversight from service leaders. Staff on CAU were aware of the sepsis ‘golden hour’ and could explain the pathway. Sepsis is a serious condition which is the result of underlying infection and can lead to organ failure and death. Poorly patients were fast tracked from the ED to CAU. Children’s early warning scores would be completed. The admissions board on the unit had coloured magnets next to the names of patients to show staff how regular observations were required. Raised early warning scores

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 273 would lead to a senior nurse review, then a doctor review, and a score of seven or more would raise the alert to the paediatric emergency team, which consisted of a consultant, a senior registrar and a senior nurse. Staff on Buxton ward told us they often had to treat more than four high dependency (HDU) patients at a time, despite only having four HDU beds. One staff member told us that HDU care could be provided by a HDU competent nurse in the treatment room on CAU when Buxton ward did not have capacity. The treatment room is a room for a single patient, with a resuscitation trolley and equipment set up for patients to receive specific treatments that would not be appropriate to receive in a bay. The room is next to the nursing station which means that nursing staff could quickly attend to patients in the treatment room. Neonatal early warning scores were consistently recorded in neonatal notes from admission. This meant that babies at risk of deterioration were more likely to be identified and escalated in a timely manner. Staff on Buxton ward could tell us about the process for poorly children requiring transfer out of the children’s service. Causes for transfer could include nursing concerns, medical concerns, elevated early warning scores, and failure to respond to treatment. Once a bed was found for the patient, support would be implemented by the senior leaders to accommodate staffing resource and assistance with the transfer. A paediatric nurse and doctor would remain with the child until the children’s acute transport service (CATS) team arrived. Should intubation be required, the child would be intubated in theatre. A paediatric anaesthetist would assist and stay with the child.

Nurse staffing The service did not have enough nursing staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. The trust has reported their staffing numbers at March 2018 and at September 2018 for services for children and young people. The number of actual staff (WTE) has remained stable between the two points in time, although the trust has increased their planned establishment for nursing staff in services for children and young people. For this reason, the fill rate has decreased from 95.4% in March 2018 to 91.6% in September 2018. As at March 2018 As at September 2018 Actual Planned Actual staff – staff – staff – Planned Site WTE WTE Fill rate WTE staff – WTE Fill rate Trust wide 163.3 171.2 95.4% 162.7 177.6 91.6% (Source: Routine Provider Information Request (RPIR) - Total staffing tab) Bank staff were used throughout the service, with agency use in all areas except the neonatal unit. This was like our findings at our last inspection, where registered nursing levels often fell below set standards and bank, agency and healthcare assistants were used to increase staffing numbers on shifts. The senior leadership team had increased the nursing establishments, and these establishments reflected the required uplift of nursing staff for 2019. A staffing options paper had gone to the board at the time of our inspection but there was no outcome at that time. There were plans to increase student nursing places and increase newly qualified recruits in to the service. The plans included incentivised recruitment. 20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 274

When we asked staff what they felt worried about, several staff told us that skill mix was a concern. Staff told us that there was not enough high dependency (HDU) competent nurses for the increased acuity of the patients. This was identified at our last inspection where we found there were insufficient numbers of HDU trained nurses for the demand on the service. A safer staffing model was used three times a day to review patient acuity and staffing. An electronic rostering system was used to create rotas on the NNU, however this did not consider the experience of staff. The safer staffing tool was updated on an electronic tablet twice daily. On Buxton ward, the flow coordinator completed the off-duty rotas and always scheduled a nurse with central line competency and a nurse who held the European Paediatric Advanced Life Support (EPLS) competency on each shift. The Jenny Lind outpatient department was led by two health care assistants with managerial support provided by the matron and a senior nurse. Safer staffing reviews undertaken on the NNU demonstrated a shortfall of registered nurses and qualified in service (QIS) nurses against required British Association of Perinatal Medicine (BAPM) standards. The required BAPM standard is for 70% of nurses on an NNU to be QIS, at the time of our inspection 58% of NNU nurses were QIS. There were plans to use another university to put nurses on the QIS pathway. At the time of our inspection, a business case was being submitted to the board to increase staffing on the NNU. Throughout the clinical locations of the service, we found that existing staff were working flexibly to support the staffing needs of the service. Bank staff or agency staff used had become regular staff to the clinical locations of the service. This allowed rota’s to be covered safely. There was senior nurse cover for the service at weekends. The senior nurses each provided cover one weekend in every six weekends.

Vacancy rates From September 2017 to August 2018, the trust reported a vacancy rate of 6.6% for qualified nursing staff in children’s services. The trust did not have a target for vacancy rate. (Source: Routine Provider Information Request (RPIR) - Vacancy tab) Managers of clinical locations throughout the service were aware of their individual vacancy rates. All managers could state what the recruitment plans were to increase their staffing numbers, as well as how shifts were covered.

Turnover rates From October 2017 to September 2018, the trust reported a turnover rate of 11.7% for qualified nursing staff in children’s services. This was higher than the trust target of 10.0%. (Source: Routine Provider Information Request (RPIR) – Turnover tab)

Sickness rates Between September 2017 to August 2018, the trust reported a sickness rate of 4.6% for qualified nursing staff in children’s services. This was higher than the trust target of 3.5%. (Source: Routine Provider Information Request (RPIR) – Sickness tab)

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The senior managers of the service acknowledged that nurses in the service were under a lot of pressure and some were experiencing burnout. The implementation of the senior nurse rota at weekends was introduced to help with this, alongside the increased staffing papers that had been submitted to the board.

Bank and agency staff usage From September 2017 to August 2018, the trust reported that 24,716 of the 409,606 establishment hours were filled by bank staff (6.0%) and 249 hours were filled by agency staff (0.1%). There were 23,188 hours (5.7%) that needed to be covered by bank or agency staff but were unfilled. A breakdown of bank and agency usage by staff type is shown below: Total establishment Staff type Bank hours Agency hours Unfilled hours hours Qualified 10,804 (3.2%) 12 (<0.1%) 19,844 (5.8%) 340,412 Non-qualified 13,912 (20.1%) 237 (0.3%) 3,344 (4.8%) 69,194 Total 24,716 (6.0%) 249 (0.1%) 23,188 (5.7%) 409,606 (Source: Routine Provider Information Request (RPIR) - Nursing bank agency tab)

Agency staff had a competency pack to complete which was managed by the nursing team on Buxton ward.

Medical staffing The service had enough medical staff, with mostly the right mix of qualification and skills, to keep patients safe and provide the right care and treatment. The trust has reported their staffing numbers at March 2018 and at September 2018 for services for children and young people. At September 2018, the trust reported an over-establishment of 1.0 WTE for medical and dental staff in services for children and young people (a fill rate of 101.2%). As at March 2018 As at September 2018 Actual Planned Actual staff – staff – staff – Planned Site WTE WTE Fill rate WTE staff – WTE Fill rate Trust wide 82.2 69.4 118.5% 77.1 76.1 101.2% (Source: Routine Provider Information Request (RPIR) –Total staffing tab)

Medical staffing vacancy levels had been on the service’s risk register since 2017; the most recent update indicated there had been some improvement in the tier one (junior doctor) rota, with unfilled shifts now only once to twice a month but issues at tier two (middle grade) were unresolved, where there were four unfilled shifts a week on average. Tier two staffing issues were mitigated with internal locum staff and the use of the advanced neonatal nurse practitioner (ANNP) team. A business case had been approved for an additional tier two member of staff to the rota. Medical staffing on the NNU was on the service’s risk register. The use of physician associates was being considered on the NNU. There was a budget for one physician associate, although this was still in the planning stage at the time of our inspection. There were four whole time equivalent (WTE) dedicated consultants on the CAU rota, with additional support from the on-call consultant across the service. These consultants were 20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 276 supported by four WTE advanced nurse practitioners. Consultant cover was between 8am and 10pm Monday to Friday, 2pm to 10pm at weekends and on call support outside of these hours. This was an improvement from our last inspection where we found that consultant cover on CAU did not meet national guidance. All children on the ward were seen every day by a consultant, with an additional round being undertaken each afternoon for high dependency children.

Vacancy rates From September 2017 to August 2018, the trust reported an over-established vacancy rate of - 4.1% for medical and dental staff in children’s services. The trust did not have a target for vacancy rate. (Source: Routine Provider Information Request (RPIR) – Vacancy tab)

Turnover rates From October 2017 to September 2018, the trust reported a turnover rate of 3.2% for medical and dental staff in children’s services. This was lower than the trust target of 10.0%. (Source: Routine Provider Information Request (RPIR) – Turnover tab)

Sickness rates From September 2017 to August 2018, the trust reported a sickness rate of 1.0% for medical and dental staff in children’s services. This was lower than the trust target of 3.5%. (Source: Routine Provider Information Request (RPIR) - Sickness)

Bank and locum staff usage From September 2017 to August 2018, the trust reported that 3,108 of the 158,723 establishment hours were filled by bank staff (2.0%) and 411 hours were filled by medical locum staff (0.3%). There were no hours that needed to be covered by bank or medical locum staff that were unfilled. A breakdown of bank and medical locum usage by unit/ward is shown below: Total establishment Unit/ward Bank hours Locum hours Unfilled hours hours NICU 1,576 (3.4%) 0 0 46,720 Paediatric medicine 940 (1.1%) 411 (0.5%) 0 85,827 Paediatric surgery 592 (2.3%) 0 0 26,176 Total 3,108 (2.0%) 411 (0.3%) 0 158,723 (Source: Routine Provider Information Request (RPIR) - Medical agency locum tab)

Staffing skill mix As at July 2018, the proportion of consultant staff reported to be working at the trust was the same as the England average and the proportion of junior (foundation year 1-2) staff was lower.

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Staffing skill mix for the 56 whole-time equivalent staff working in children’s services at Norfolk and Norwich University Hospitals NHS Foundation Trust This England Trust average Consultant 44% 43% Middle career^ 3% 7% Registrar Group~ 50% 43% Junior* 4% 7%

^ Middle Career = At least 3 years at SHO or a higher grade within their chosen speciality ~ Registrar Group = Specialist Registrar (StR) 1-6 * Junior = Foundation Year 1-2

(Source: NHS Digital Workforce Statistics)

Records Staff across the service were not consistent in keeping detailed records of patients’ care and treatment. Some records were clear, up-to-date and easily available to all staff providing care, whilst others were not. We reviewed 11 sets of patient records. We found three had incomplete fluid balance charts. Eight of the sets of records were up to date, legible and with consistent and appropriate use of early warning scoring. We reviewed three sets of notes on the NNU. Intravenous (IV) fluids charts were not always completed so it was not clear when IV fluids had been stopped. There were no personalised care plans in the records, we were unable to determine when observations were due, or what procedures were to be undertaken. Each baby’s care was categorised into high dependency care, intensive care and special care rather than care plans being tailored to individual babies. The organisation of notes was poor on the NNU. The nurses were unsure of how often the babies were due to be weighed, which could lead to potential problems with prescribing medications, and determining nutritional requirements and volumes of required feed. The day ward had recently changed their diary from a paper to an electronic system for all admissions and attendances to the unit. This had led to occasional children turning up unexpectedly. Staff were aware of a flagging system on the electronic patient administration system. This alerted staff to several important issues such as if a patient had Methicillin-resistant Staphylococcus aureus (MRSA), if a child had allergies or if a child was on a child protection plan. MRSA is a group of bacteria that lead to difficult to treat infections.

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The service discharged children electronically when they went home. The discharge document covered information relating to the whole patient pathway. The document was sent to GP’s, community midwives and outreach services as necessary. The system allowed access to previous clinical correspondence and documentation for nursing, medical and surgical teams. The service had gone out to tender for an electronic observation recording tool. At the time of our inspection, patient observations were recorded in paper notes. We saw sepsis stickers in patients’ notes as reminders of what sepsis signs to look for.

Medicines The service sometimes followed best practice when prescribing, giving, recording and storing medicines. Patients received the right medication at the right dose at the right time. Medicines were stored securely in restricted access rooms, and in locked cupboards and medicine fridges throughout the service. Controlled drugs were securely stored and drug reconciliation records were consistently complete and correct. Controlled drugs are medicines that have their possession, prescription, administration and disposal managed under the Misuse of Drugs legislation. We checked six controlled drugs at random throughout the service and all records were up to date and correct. Medication fridge temperature checks were often missing throughout the service. We looked at fridge temperature checks between November 2018 and January 2019. All checks were completed in CAU. One check was missing on the day ward for the chemotherapy fridge. There were eight missing checks on Buxton ward, as well as 21 days of missing ambient room checks, and eight days of missing checks of the parenteral nutrition fridge. We were not assured that fridge temperature breaches were actioned by staff. We saw entries next to temperature breaches by pharmacy staff with the reason for the breaches. Reasons were often recorded as thermometer resets not being completed. We also saw reasons relating to temperature probes slipping out of place or not being inside fridges, and fans being obstructed in fridges. A senior nurse on Buxton ward told us that the checking of medication fridges was completed by housekeeping staff. This issue was raised at our last inspection where we found that medication fridge temperatures were not consistently recorded, therefore we were not assured this issue was addressed by the service. There was a mix of electronic and paper prescribing across the service. This was not always well managed and there were 34 medicines related incidents between November 2018 and January 2019. Seven of these were prescribing incidents. The matron told us the main theme for medicine related incidents was the new electronic prescribing system. As learning, all staff were required to complete electronic prescribing training and pharmacy were due to issue communications to staff across the trust to ensure staff know how to check previous drug doses. We checked three medication administration records on CAU and all showed that allergy status, weight and drug histories were recorded and signed.

Incidents The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team 20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 279 and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.

Never Events Never events are serious incidents that are entirely preventable as guidance, or safety recommendations providing strong systemic protective barriers, are available at a national level, and should have been implemented by all healthcare providers. Each never event type has the potential to cause serious patient harm or death but neither need have happened for an incident to be a never event. From November 2017 to October 2018, the trust reported no incidents classified as never events for children’s’ services. (Source: Strategic Executive Information System (STEIS)) Further review of information showed that a never event was reported on NNU where a baby received the wrong group of plasma by transfusion. This was investigated and lessons had been identified for learning from this incident. Immediate actions were taken including communication to the laboratory and NNU teams after the incident, and the drawers where the plasma was stored were sealed and made inaccessible as an interim measure until a solution was identified. A review of training and the relevant policies was undertaken, as well as an audit which led to the blood products guidelines being updated along with a transfusion sheet now requiring double sign off by both medical and nursing staff in advance of a transfusion.

Breakdown of serious incidents reported to STEIS In accordance with the Serious Incident Framework 2015, the trust reported five serious incidents (SIs) in children’s services which met the reporting criteria set by NHS England from November 2017 to October 2018. The breakdown by incident type was as follows: Diagnostic incident including delay meeting SI criteria (including failure to act on test results) with one (20% of total incidents). Apparent/actual/suspected self-inflicted harm meeting SI criteria with one (20% of total incidents). A suicide attempt in the service had led to the mental health matron undertaking a risk assessment of potential ligatures throughout the service, and the implementation of one to one care for anyone admitted with acute mental health problems under the age of 16 years. Abuse/alleged abuse of a child patient by staff with one (20% of total incidents). This incident was under police investigation at the time of our inspection and the staff member had been suspended pending that investigation. Health care acquired infection (HCAI)Infection control incident meeting SI criteria. A baby became unwell with sepsis on the NNU. The investigation identified that the baby had a meningitis and endophthalmitis, which is severe inflammation of the eye tissues, caused by the pseudomonas bacteria. It had been identified that the baby was being cared for at the time of the incident in a cot next to a sink where regular testing had also identified pseudomonas was present in the sink. Immediate actions were approved by the clinical commissioning group. Actions included improved cleaning schedules, the introduction of permanent fixtures between sinks and cot spaces to prevent water splashback, a range of strengthened infection prevention and control measures for

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 280 the NNU, and a series of maintenance improvements such as re-mounting apron rolls away from bins on the unit. Infection prevention and control audits and screening were performed and action plans from those audits were monitored regularly at the time of our inspection. Treatment delay meeting SI criteria with one (20% of total incidents). A baby had required resuscitation and admission to the NNU. The cause of collapse was infection with group B streptococcus leading to sepsis and multi-organ illness, including meningitis, resulting in severe brain injury. A review of the notes found that early signs of deterioration did not lead to an escalation of response. During the initial resuscitation, antibiotics were not prioritised. An action plan had been implemented and monitoring of this was ongoing. (Source: Strategic Executive Information System (STEIS)) The clinical lead gave an example of learning from a serious incident on the NNU. This incident is not listed in the identified SIs above. A baby had been intubated and despite blood gas levels not improving, the baby was not extubated until a later time. Learning from this included the completion of a root cause analysis, a new flowchart for staff to follow for difficult airways and regular simulation training sessions. However, these sessions were not well attended due to service capacity and low staffing numbers. The service did not state if this was being addressed, therefore we were not assured that the learning from this incident had been effective. Staff could talk about learning from incidents. One example was given where learning from an incident led to improvements in record keeping and filing. This learning was shared in team meeting minutes, the ‘lightning learning’ poster created by the manager, and was found in the ‘read me’ folder in the staff room. Staff understood duty of candour and we saw evidence of duty of candour being fulfilled in the investigation reports of four incidents we reviewed. There was a ‘high reporting, low risk’ mantra to incident reporting. Moderate risks and medications incidents were discussed at the ‘serious incident group’ meetings held daily Monday to Friday. The CAU manager, service matron and two band 6 staff were trained as incident investigators. There were perinatal and neonatal mortality and morbidity meetings held once monthly. These were attended by medical trainees, medical consultants, advanced neonatal nurse practitioners (ANNPs), the risk nurse, and the ward manager for NNU. Minutes from mortality and morbidity meetings were emailed to attendees. Feedback from incidents was shared in a ‘risky business’ newsletter which was produced monthly and displayed in the staff rooms. There was a once weekly communication meeting for the NNU which was multidisciplinary with notices, highlights and learning from the week being discussed.

Safety thermometer The Safety Thermometer is used to record the prevalence of patient harms and to provide immediate information and analysis for frontline teams to monitor their performance in delivering harm free care. Measurement at the frontline is intended to focus attention on patient harms and their elimination. Data collection takes place one day each month – a suggested date for data collection is given but wards can change this. Data must be submitted within 10 days of suggested data collection date.

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Data from the Patient Safety Thermometer showed that the trust reported one new pressure ulcer (levels 2, 3 and 4), no falls with harm (levels 3 to 6) and no new urinary tract infections (level 3) in patients with a catheter from October 2017 to October 2018 for children’s services. (Source: NHS Digital) Safety thermometer information was uploaded once monthly to a national monitoring system. This included data on documentation information, risk assessments, catheter care and cannula care. A senior nurse on Buxton ward told us that a paediatric specific safety thermometer was introduced two months prior to our inspection, and this was completed the first week of each month. On the NNU, safety thermometer trends were completed once a month. This included pressure ulcers, neonatal early warning scores, extravasations, where a drug leaks from the vein into or onto the surrounding skin, and urinary tract infections from indwelling catheters. We were unable to view the safety thermometer figures, the ward manager was not sure where the data goes once it was submitted, or who reviewed it. Therefore, we were not assured that learning was being shared amongst medical and nursing staff.

Is the service effective? Evidence-based care and treatment The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance. The service had a local and national audit programme in place. Audits included the use of children’s early warning scores; drug protocol audits; audit against National Institute for Health and Care Excellence (NICE) guidance for feverish children; and audits of patient experience. For the period April 2018 to March 2018, 43 audits were registered for the service. Of these, four were abandoned, one was reported as being in the planning stage but we saw no evidence it was commenced, two were in progress but we saw no evidence they were completed, and 37 were completed. We reviewed audit results for children’s early warning scores (CEWS), compliance to patient group directions, paediatric documentation. All three audits had associated action plans for areas requiring improvement. These plans included named leads for taking action and completion dates with detail on how measures were achieved. We saw audits to check compliance against 19 applicable NICE guidelines. Results showed that the service was fully compliant with six of these guidelines, partially compliant with 12, and not compliant with one. These results were risk scored. We did not see evidence in the children’s board minutes of any audit scrutiny or discussion. There was implementation of the Academy of Medical Royal Colleges Guidance for Taking Responsibility: Accountable Clinicians and Informed Patients. This meant that individual named clinicians took accountability for a patient’s care on each shift and that patients knew whom their responsible clinician and named nurse were. The neonatal unit participated in the Baby Life Support Systems (BLISS) Baby Charter, which is a scheme that ensures a family-centred approach in the care of sick and premature babies.

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The service was working towards accreditation for the Baby Friendly initiative by UNICEF, which improves the practice of infant feeding in health care settings. This meant that trained staff could support parents in feeding their babies. The NNU was approved to provide sub speciality training as part of the national sub speciality training scheme, also known as the NTN Grid scheme. This meant that paediatric trainees could specialise in neonatal medicine on the unit. The pre-operative pathway was established and worked well across all areas of the service, from the Jenny Lind Outpatients Department, to pre-assessment on the day ward, admission to Buxton ward, surgery in main theatres, paediatric recovery, and back to Buxton ward before discharge home. Policies reviewed on the neonatal unit such as pain and sedation assessment in neonates and developmental care clinical guidelines were in line with the regional neonatal network. The NNU was part of a regional benchmarking group who met frequently to establish clinical benchmarks in neonatal medicine and care.

Nutrition and hydration Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary. Food and fluid balance was recorded on charts throughout most of the service. If a child or young person was not in the service for long, then entries were made in their notes of what they had eaten and drank. On the NNU we reviewed three fluid balance charts that had not been completed. We also saw inconsistent recording of baby’s’ weights on the NNU. This meant there was a risk of inappropriate amounts of feed and other nutrition being given that depended on the weight of the baby. Kitchen staff attended the ward areas three times a day to find out what the children wanted to eat. Snacks and sandwiches were always kept in a fridge. One child told us they were happy with their meal options and one parent told us that they were offered sandwiches by staff. There was an infant feeding keyworker on CAU. This role included providing support to families and staff by providing resources and support with breastfeeding. This member of staff had completed a UNICEF breastfeeding training day and was waiting to do a tongue tie competence which meant they could assess and refer tongue tie babies in the future. There was an infant feeding policy in place which provided guidance to staff on all aspects of infant feeding and where to gain support.

Pain relief Staff assessed and monitored patients regularly to see if they were in pain. They supported those unable to communicate using suitable assessment tools and gave additional pain relief to ease pain. There was a pain link nurse on the NNU. They had attended an external course and completed an assignment to demonstrate their competence, accredited by a university. Although there was no pain team for neonates, the practice development nurse provided support to the link nurse around effective pain relief and pain management.

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There was a pain link nurse on Buxton ward, who was also supported by the practice development nurse, but they had not yet attended the external course. There was a resource folder on the NNU to ensure that pain relief guidelines were being followed. The FLACC (face, legs, arms, cry and consolability) pain scoring tool was used to assess pain in children under six years old. The pain team were in the process of considering a revised FLACC tool for cognitively impaired children. The Wong-Baker pain scoring tool was used in children older than six years. This is a tool that uses a series of faces experiencing different levels of pain, for children to self-identify their pain levels. Pain scoring tools were available in all admission folders throughout the service. There was a pain relief patient group directive (PGD) in place for nursing staff with the appropriate competency, so that the first dose of pain relief could be provided by a nurse quickly. There were stickers in notes when pain relief was administered as part of a PGD. Having a PGD in place means that a certain type of medication is readily available for all patients requiring it, and can be given by a competent nurse without an individual doctor’s prescription. For example, paracetamol could be administered to a child with mild to moderate pain. There were three nurse prescribers across the service. There were plans for more nurses to complete the nurse prescriber course. There was a once monthly pain meeting, with attendance by an anaesthetist, nurses and medical doctors. Agenda items included best practice and policies.

Patient outcomes Managers monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them. The service actively participated in a range of national and local clinical audits. There was a comprehensive audit plan in place that included detail on required improvements, proposed actions and named leads for those actions.

Paediatric diabetes audit 2018 The table below summarises Norfolk and Norwich University Hospital’s performance in the 2018 National Paediatric Diabetes Audit. Comparison Metrics Trust Meets national to other (Audit measures) performance standard? hospitals Completion rate for key health checks for patients aged 12+ (There are seven key care Within No current processes recommended by NICE 83.4% expected standard for patients with Type 1 diabetes that range should be performed at least annually) Case-mix adjusted mean HbA1c No current (HbA1c levels are an indicator of 64.0 Positive Outlier standard how well an individual’s blood

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 284 glucose levels are controlled. This measure is provided for benchmarking against other providers during an audit year) Median HbA1c (This measure is provided to give an indicator of how performance has No clinically No current changed between the previous and 61.0 significant standard latest audit reports. A change of 1 change mmol/mol is deemed to be clinically significant) (Source: National Paediatric Diabetes Audit) National Paediatric Diabetes Audit 2017: the trust is ‘much better’ than the national comparison for blood glucose control.

National Neonatal Audit Programme The table below summarises Norfolk and Norwich University Hospital’s performance in the 2017 National Neonatal Audit Programme against measures related to maternity care. Comparison Metrics Hospital Meets national to other (Audit measures) performance standard? hospitals Do all babies <32 weeks gestation have a temperature taken within an hour of admission that is 36.5ºc-37.5ºc? (Low body Within temperature on admission is 59.6% expected associated with increased  range complications, such as hypoglycaemia, jaundice and respiratory distress, and death in pre-term infants) Is there a documented consultation with parents by a senior member of the neonatal team within 24 hours of admission? 95.9% Positive Outlier  (Timely consultation with parents/carers is crucial to allaying fear and anxiety and improves the parent/carer experience) Do all babies < 1501g or a gestational age of < 32 weeks at birth receive appropriate screening for retinopathy of Within prematurity (ROP) 97.4% expected  (ROP is a preventable cause of range blindness in pre-term infants provided it is detected and treated in a timely way)

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Do all babies with a gestation at birth <30 weeks receive a documented follow-up at two years gestationally corrected age? 80.7% Better (It is important that the development  of pre-term babies is monitored by a paediatrician or neonatologist after discharge from the neonatal unit) (Source: National Neonatal Audit Programme) The service was an outlier for ‘parental consultation within 24 hours of admission’. We saw an action plan which was implemented to address this outlier and more recent data has shown an improvement in this metric. The service was better or equal to national targets in five out of seven measures. A peer review was carried out on the NNU in April 2018, and the unit was rated as 81.3% compliant overall.

Emergency readmission rates within two days of discharge The data shows that from May 2017 to April 2018 there was a higher percentage of patients aged 1-17 years old readmitted following an elective admission for paediatric surgery or paediatric medical oncology compared to the England averages.

Emergency readmissions within two days of discharge following elective admission among the under 1 age group, by treatment specialty (MAY 2017 to APRIL 2018) Norfolk and Norwich University Hospitals NHS Specialty Foundation Trust England Readmission Discharges Readmissions Readmission rate (n) (n) rate

No speciality at this trust had six or more readmissions.

Emergency readmissions within two days of discharge following elective admission among the 1-17 age group, by treatment specialty (MAY 2017 to APRIL 2018) Norfolk and Norwich University Hospitals NHS Foundation Trust England Specialty Readmission Discharges Readmissions Readmission rate (n) (n) rate Paediatric 1.4% 575 8 0.6% Surgery Paediatric Medical 10.0% 60 6 2.5% Oncology

No other speciality at this trust had six or more readmissions.

The tables below show the percentage of patients (by age group) who were readmitted following an emergency admission. The tables show the three specialties with the highest volume of

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 286 readmissions and only those specialties where six or more readmissions recorded are shown in the table. The data shows that from May 2017 to April 2018 there was a similar percentage of under ones readmitted following an emergency admission compared to the England average and a higher percentage of patients aged 1-17 years old readmitted following an emergency admission for all three specialties compared to the England averages.

Emergency readmissions within two days of discharge following emergency admission among the under 1 age group, by treatment specialty (MAY 2017 to APRIL 2018) Norfolk and Norwich University Hospitals NHS Specialty Foundation Trust England Readmission Readmissions Readmission rate Discharges (n) (n) rate Paediatrics 3.5% 2,051 71 3.4% No other speciality at this trust had six or more readmissions.

Emergency readmissions within two days of discharge following emergency admission among the 1-17 age group, by treatment specialty (MAY 2017 to APRIL 2018) Norfolk and Norwich University Hospitals NHS Foundation Trust England Specialty Readmission Readmissions Readmission rate Discharges (n) (n) rate

3.6% 3,939 141 2.8% Paediatrics

Paediatric 3.9% 515 20 2.1% Surgery Paediatric Medical 6.3% 127 8 4.8% Oncology (Source: Hospital Episode Statistics, provided by CQC Outliers team)

Rate of multiple emergency admissions within 12 months among children and young people for asthma, epilepsy and diabetes From June 2017 to May 2018, the trust performed similar to the England averages for the percentage of patients aged 1-17 years old who had multiple readmissions for asthma, diabetes, and epilepsy.

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Rate of multiple (two or more) emergency admissions within 12 months among children and young people for asthma, epilepsy and diabetes (for children aged under 1 year and 1 to 17 years). (JUNE 2017 to MAY 2018)

Norfolk and Norwich University Hospitals NHS Foundation Trust England At least one Long term Multiple admission Two or more Multiple condition admission rate (n) admissions (n) admission rate Asthma Under 1 - - - 8.6% 1 to 17 15.8% 101 16 16.1% Diabetes Under 1 - - - 16.7% 1 to 17 15.4% 52 8 13.0% Epilepsy Under 1 * * * 32.9% 1 to 17 31.8% 44 14 27.4% Note - For reasons of confidentiality, numbers below 6 and their associated proportions have been removed and replaced with ‘*’. (Source: Hospital Episode Statistics, provided by CQC Outliers team) Senior managers of the service told us that higher readmission and multiple admission rates were due to coding errors. CAU was an admissions and attendance assessment unit, meaning that all patients presenting there regardless of reason for attendance were recorded as admissions. This included patients given 24 and 48-hour open access to the service. The rationale for this was that the tariff and payment for the service was still being decided by the CCG’s.

Competent staff The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service. Appraisal rates This information is routinely requested within the universal provider information request spreadsheets, to be completed within a standard template. The trust was unable to provide the appropriate data and we are awaiting updated information. Once this has been received in the correct format we will be able to populate the analysis to complete this section. (Source: Trust Provider Information – Appraisal tab) Information provided by the trust showed that across registered and unregistered nursing staff, 92% of staff had up to date appraisals. 98 Percent of medical staff had up to date appraisals in the service. We reviewed two appraisal documents and found appraisals to be comprehensive and well completed. 69.7 Percent of required staff were trained in advanced neonatal life support. 62 Percent of required staff were trained in advanced paediatric life support. 86.8 Percent of required staff were 20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 288 trained in new born basic life support and 86.1% of staff were trained in paediatric basic life support. The service had four high dependency beds on Buxton ward. Children requiring intensive care were treated on the adult intensive care unit (ICU) were cared for by nurses who had the necessary paediatric competencies. There was a comprehensive competency booklet for adult nursing staff to work through that ensured they could deliver safe care to children. The senior nurse on ITU was the paediatric link nurse for the unit. There were plans for some adult ITU nurses to shadow at the local tertiary paediatric intensive care unit (PICU) to increase their confidence and competence, although all adult ITU nurses had children’s competencies. There was a core team of nurses in adult ITU that were European Paediatric Advanced Life Support (EPLS) trained. There were concerns around the NNU staff having to cover other areas of the service and not feeling competent to do so. Senior managers told us that recruitment of paediatric nurses was ongoing and an urgent options paper was going to the board regarding paediatric staffing. A working agreement regarding staff movement to the children’s ward had been developed, along with a rolling training day for staff, to enhance their competencies. This was being introduced around the time of our inspection so we were unable to assess the effectiveness of this. On the NNU separate meetings were held for the staff working in the special care and transitional care rooms. These meetings were initiated because staff felt there was not as much focus on their development than their colleagues working in the high dependency and intensive care rooms. The meetings focus on ideas for improvement and responsibilities. A healthcare assistant from the children’s outpatient’s department was working on the day ward. The member of staff had asked to develop skills and competencies outside of their role and this was being facilitated on the day ward. On Buxton ward, 33% of registered nursing staff were trained in European Paediatric Advanced Life Support (EPLS). 38 Percent were trained to this standard on the CAU and 75% were trained on the day ward. The service ensured that at least two staff were always on shift to cover each clinical location in the service, who were trained to this standard. Play specialists received training on clinical holding as opposed to restraint. This was supported by a trust policy on clinical holding. The use of restrictive physical interventions that enable staff to effectively assess or deliver clinical care and treatment to individuals who are unable to comply. Advanced practice days were held for some competencies such as the administering of medicines through an epidural route. Competencies were assessed by specialist nurses, the practice educator or previously assessed band six nurses. Workshops and training sessions were provided to enhance skills and competences, particularly for new staff. Several staff told us that the practice development nurse was proactive and supportive. Newly qualified staff had ongoing support and worked supernumerary for one month, the with practice educator supporting them on and off the ward. There was a monthly meet up as a group for newly qualified staff, as well as ‘personal preceptor’ and ‘clinical preceptor’ meetings.

Multidisciplinary working

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Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care. CQC Children and Young People’s Survey 2016 – Q23 In the CQC Children and Young People’s Survey 2016 the trust scored 8.2 out of ten for the question ‘Did the members of staff caring for your child work well together?’ This was about the same as other trusts. (Source: CQC Children and Young People’s Survey 2016, RCPCH) The service worked well with other major tertiary centres. There were established links in place so that children with specific needs, for example burns and cardiology, were transferred to the appropriate hospital, with visiting specialists providing some outpatient clinics throughout the year. A service level agreement was in place with the local child and adolescent mental health service (CAMHS). This meant that a duty worker was available Monday to Friday. Their role was to facilitate and identify inpatient beds and generate referrals. However, this service was reduced at the weekends meaning that some children could wait up to 48 hours for a CAMHS assessment. The mental health matron supported staff in the care of children with acute mental health needs and we saw an example of staff being well informed in the care of a child with acute mental health needs. We saw evidence of good multidisciplinary working with CAMHS which resulted in well documented, risk assessed care, and understanding of patient needs. There were daily safety huddles that had multidisciplinary attendance with representation from medical, nursing and therapy staff such as physiotherapists and dietitians where required. There was a multidisciplinary approach to care for children with long term conditions, with medical staff working closely with specialist nurses in the care of the child. A NNU representative attended a meeting once every two months with the regional neonatal network benchmarking group. The meetings aimed to provide feedback within the region of learning and to gain collaborative advice and support. Transition clinics were held in the Jenny Lind out patients’ clinic, where young people with long term conditions could attend joint clinics with their paediatrician and the consultant for their care as an adult. There was no transition lead nurse for the service. Senior managers told us that a proposal was put forward to the board to have 12 adolescent beds on Cringleford ward, but this proposal was declined. Clinical specialist nurses lead adolescents through to adult services. A named nurse and doctor for children transitioning into adult services was part of a longer-term plan. This was like what we found on our last inspection, when the service had lost access to four transitional beds for young people aged 16 to 18.

Seven-day services Consultant cover for the service was seven days a week. This included the consultant on call rota for all clinical locations of the service. There was access to physiotherapy, pharmacy and diagnostic services seven days a week.

Health promotion

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We spoke with parents and carers who felt that they were encouraged in supporting the care of their children whilst admitted to the service. We saw that the service promoted and supported breastfeeding, however we did not see any evidence of other health improvement strategies throughout the service such as tackling smoking and obesity.

Consent, Mental Capacity Act and Deprivation of Liberty Safeguards Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. We saw examples of care that demonstrated staff knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care. Mental Capacity Act and Deprivation of Liberty training completion The trust set a target of 90% for completion of Mental Capacity Act (MCA) and Deprivation of Liberty training. A breakdown of compliance for Mental Capacity Act (MCA) and Deprivation of Liberty Safeguarding (DoLS) courses at September 2018 for qualified nursing staff in services for children and young people is shown below:

Number of Number of eligible staff trained staff Completion Trust Met Name of course (YTD) (YTD) rate Target (Yes/No) Mental Capacity Act Level 1 159 185 86% 90% No Deprivation of Liberty Safeguards 159 185 86% 90% No

Qualified nursing staff did not meet the trust training target for either of the training modules relating to the Mental Capacity Act (MCA) and Deprivation of Liberty (DoLS). A breakdown of compliance for Mental Capacity Act (MCA) and Deprivation of Liberty Safeguarding (DoLS) courses at September 2018 for medical and dental staff in services for children and young people is shown below:

Number of Number of eligible staff trained staff Completion Trust Met Name of course (YTD) (YTD) rate Target (Yes/No) Mental Capacity Act Level 1 42 67 63% 90% No Deprivation of Liberty Safeguards 42 67 63% 90% No

Medical staff did not meet the trust training target for either of the training modules relating to the Mental Capacity Act (MCA) and Deprivation of Liberty (DoLS). (Source: Trust Provider Information Request – Training tab) Senior managers in the service told us that compliance to training was inaccurately represented due to the data systems used and how compliance was measured. They told us that possible

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 291 improvements to the system were being explored in a bid to gain a truer account of this training compliance. Staff understood how and when to assess whether a patient had the capacity to make decisions about their care. They followed the trust policy and procedures when a patient could not give consent. Staff understood Gillick competence, which is an assessment as to whether a child has the appropriate understanding and maturity to consent to care. Gillick competence was fully explained in the trust’s consent policy which was being updated at the time of our inspection. Competence was assessed primarily by age, if a child was aged 12 or over. If the child also demonstrated that they were of sound mind and that they could make decisions about their care then they were deemed to have the Gillick competence. We saw the assessment of Gillick competence recorded in patient notes with signatures by young people.

Other CQC Survey Data

CQC Children and Young People’s Survey 2016 Data The trust performed worse than other trusts for one question and about the same as other trusts for the remaining four questions relating to effectiveness in the CQC Children and Young People’s Survey 2016. The trust performed worse than other trusts for the following question: Q21. Did you feel that staff looking after your child knew how to care for their individual or special needs? (Source: CQC Children and Young People’s Survey 2016, RCPCH)

Is the service caring? Compassionate care Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. CQC Children and Young People’s Survey 2016 The trust performed worse than other trusts for two questions and about the same as other trusts for the remaining eight questions relating to compassionate care in the CQC Children and Young People’s Survey 2016. The trust performed worse than other trusts for the following questions: Q22. Were members of staff available when your child needed attention? Q58. Was it quiet enough for you to sleep when needed in the hospital? (Source: CQC Children and Young People’s Survey 2016, RCPCH) The service displayed Friends and Family Test (FFT) results throughout its clinical locations. For example, we saw that FFT results for December 2018 were 89.3% of patients would recommend Buxton ward, based on 35 responses. We also saw that 100% of patients would recommend the children’s assessment unit (CAU), based on 46 responses in November 2018. Parents on the neonatal unit (NNU) told us they felt very clearly communicated with. A parent on the NNU told us they saw the same staff regularly and that the staff really knew their baby.

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Another parent on the NNU told us they felt happy to leave their baby with staff as they were confident in the staff. The parent also told us they felt very supported in establishing breastfeeding. A carer on Buxton ward told us that when their child was being moved back to the ward, staff made sure the patient was not returned to the room they had previously experienced a cardiac arrest in, to avoid any upset. The matron for the service told us they conducted a daily walk around and introduced them self to each patient and their families and carers.

Emotional support Staff provided emotional support to patients to minimise their distress. CQC Children and Young People’s Survey 2016 The trust performed about the same as other trusts for the five questions relating to emotional support in the CQC Children and Young People’s Survey 2016. (Source: CQC Children and Young People’s Survey 2016, RCPCH) A forum was being set up on Buxton ward for parents and carers of children with complex needs. This forum was to establish peer support and was to be facilitated by nurses from the service. Parents on the NNU told us that they were getting a lot of support from NNU staff as well as other parents. Spiritual support was available to all patients and their families from a chaplaincy service across the children’s ward and the neonatal unit. The chaplaincy service supported people from different faith backgrounds and those with no faith.

Understanding and involvement of patients and those close to them Staff involved patients and those close to them in decisions about their care and treatment. CQC Children and Young People’s Survey 2016 The trust performed about the same as other trusts for the 21 questions relating to understanding and involvement of patients and those close to them in the CQC Children and Young People’s Survey 2016.

(Source: CQC Children and Young People’s Survey 2016, RCPCH) Two parents on the NNU told us they knew they could speak to staff if they had any concerns and that they always knew who was in charge. There was a play specialist team of four staff. Their work included play to provide information to children about procedures, and assisting with distraction of children undergoing investigations and procedures. One carer we spoke with told us the communication from staff was very good, and that they were invited to attend multidisciplinary meetings along with the child’s named nurse. The carer felt that staff allowed them to lead the care and staff followed.

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The NNU had comprehensive books named “welcome to the NICU family guide” for parents to take away on discharge. The booklet was started on admission and included sign offs of parent skills prior to discharge.

Is the service responsive? Service delivery to meet the needs of local people The trust planned and provided services in a way that met the needs of local people. CQC Children and Young People’s Survey 2016 The trust performed worse than other trusts for one question and about the same as other trusts for the remaining 16 questions relating to responsiveness in the CQC Children and Young People’s Survey 2016. The trust performed worse than other trusts for the following question: Q26. Were you able to prepare food in the hospital if you wanted to? (Source: CQC Children and Young People’s Survey 2016, RCPCH)

Meeting people’s individual needs The service took account of patients’ individual needs. Recreation facilities were age appropriate for the range of patients using the service. The playroom had resources and equipment for younger children, whilst the adolescent room had facilities including a game console and board games for older children. There was a variety of toys in the waiting area of the children’s outpatient department. The children’s day ward had a range of toys, books and games for patients of all ages. Buxton ward had a parents’ room and could provide a bed and bed linen for one carer per child, next to the patient’s bed. Patients on Buxton ward had access to individual televisions which were free to use. There were facilities in the adolescent room on Buxton ward to change the setting into a sensory room, led by one of four play specialists. The neonatal unit had a sitting room with a kitchen and television for parents and visitors, as well as a sibling play area. There was accommodation for parents to spend the night when their babies were very poorly. Translation services were available throughout the service with staff being able to access these services, for example, telephone translation services and patient information leaflets in a variety of languages. For the period January 2018 to December 2018, there were six patients under the age of 15 admitted to adult areas. This does not include children admitted for day surgery, maternity care or critical care. These admissions were to a range of medical and surgical wards where nurses trained to deliver care to adults were providing care to children and young people. This meant that the specific needs of children and young people might not have been met. The service did not have a dedicated transition service for children who were transitioning care into adult services. Children with long term health conditions such as asthma, epilepsy and diabetes met their adult consultants in the children’s outpatient department along with their paediatrician and a specialist nurse. There were no dedicated inpatient beds for adolescents, and the aim was for older teenagers requiring beds to be cared for in separate bays from younger children. This was the same as what we found at our last inspection. The strategy for the service

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 294 included developing a transition service although there was no indication of when or how this may be achieved. The walls and ceilings above examination and treatment beds in the outpatient department were decorated for children and young people to look at when being examined. A learning disabilities nurse had been appointed in the immediate period prior to our inspection, therefore we were unable to assess the responsiveness of this role. One carer told us that required equipment for admissions of a child with complex needs was always available and waiting on arrival. A ‘This is Me’ passport was in use for children with complex needs. This allowed staff to gain awareness and understanding of the specific needs and wishes of each individual child without parents and carers having to repeat such needs to every staff member involved in the child’s care. A specialist breastfeeding team was established to support parents on the neonatal unit. Preadmission clinics for children and young people requiring surgical admissions were held in the day unit. The play specialists prepared children and their families for the stay and this included a tour of the ward. Children receiving a general anaesthetic had a play specialist and a parent or carer with them in the anaesthetic room. This meant that children could be comforted by those close to them when undergoing a general anaesthetic, as well as having specialists to provide appropriate distraction at the same time. We observed how staff respected the individual needs of one young person who felt that being in a side room would have a negative impact on them, by placing them in a bay with other children but maintaining one to one care and observations in conjunction with the young person’s family.

Access and flow People could not access the service when they needed it. Patients have a legal right to receive treatment within 18 weeks of being referred. 45.9 Percent of children referred for surgery and 38.9% of children requiring trauma and orthopaedic treatment were treated within 18 weeks. Due to the numbers for paediatric medicine being low, we have not included that detail here to protect confidentiality. There are no national average data sets for us to compare these percentages to. However, the trust had identified these percentages as being lower than expected and had identified theatre capacity as the main reason for the referral to treatment times being at low levels. The service leads told us that offsite services were being considered to tackle surgical waiting lists. Referral to treatment times were not entered onto the service’s risk register, and had been a long- standing issue that we noted on our precious inspection. Therefore, we were not assured that the service was appropriately managing the time it took to treat children from referral.

Neonatal Critical Care Bed Occupancy

From October 2017 to September 2018, the trust’s neonatal bed occupancy has been greater than the England average in 10 of the 12 months. In September 2018, the trust’s critical care bed occupancy was 73.3%. This compares to the England average of 69.3%.

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Note data relating to the number of occupied critical care beds is a monthly snapshot taken at midnight on the last Thursday of each month. (Source: NHS England) Admissions to the children’s assessment unit could be from either the emergency department, GPs, specialist teams, midwives, community teams or from home when children with long-term conditions had open access to the trust. Admissions to the children’s day ward were elective, with children attending from home. Admissions to Buxton ward were either elective admissions booked by the waiting list coordinator; emergency admissions received from the children’s assessment unit or the emergency department; transfers from other trusts; or open access patients. If children in the emergency department required admission and the service was at capacity, the process was for the site operations team and divisional manager to facilitate a team decision could be made regarding closing the relevant clinical location, or diverting care to another hospital. Neighbouring trusts were equipped to take children of varying acuities. Children and young people awaiting transfer to a mental health bed had their care, documentation and transfer coordinated by the mental health matron. The children’s assessment unit (CAU) had implemented a criteria-led discharge process. A few conditions had been identified, such as vomiting and diarrhoea, and asthma, where the senior registrar would assess if the patient was suitable for a criteria-led discharge. For those assessed and identified, a senior nurse would discharge the patient. In the event of a patient deteriorating then the discharge responsibility would return to the medical staff. A set competency was established for senior nurses to perform this duty. This was an improvement on access and flow through the CAU from our findings in our previous inspection. The unit manager told us that they felt this process had increased the flow out of the unit and was upskilling nursing staff. However, we were unable to assess the effectiveness of the criteria led discharge due to it only being in place for approximately one month before our inspection. There were 2.5 whole time equivalent (WTE) paediatric flow coordinators in post. These were senior nurses who conduct three safety huddles daily to review flow through the service. The huddles included discussion around patients, flow through the service and areas of concern.

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Health care assistants based in the outpatient department (OPD) supported community outreach clinics to improve access and flow to the OPD when the unit had no spaces for more clinics. These included allergy, neurology and diabetes clinics. ENT, ophthalmology and plaster room clinics were also supported. Lion ward, which is for children’s day case surgeries, was used as an escalation area for adults requiring surgery. This meant that when the ward was used for escalation, children would be advised to attend Buxton ward instead. If Buxton ward did not have capacity to admit any of these children, cases would be prioritised according to clinical urgency and time on the waiting list. Those children that had their surgeries cancelled were rebooked. Data we requested for the period July 2018 to February 2019 showed that of 42 children who had their surgeries cancelled, 23 children were rebooked within 28 days. Eleven children waited between 35 and 77 days to be rebooked, and eight children were still waiting to be rebooked. A quality improvement project was underway to reduce neonatal readmissions by developing an integrated care plan. The Avoiding Term Admission in Neonatal units (ATAIN) project, which is part of NHS Improvement work, aimed to reduce the numbers of full term babies being admitted to the neonatal unit. Pathways were being reviewed for babies being admitted from the maternity ward. A breast-feeding specialist team were helping to reduce admissions for poor feeding. Work between the neonatal and postnatal managers was looking at intravenous antibiotics being given on the post-natal ward so that babies could stay with their mothers.

Learning from complaints and concerns The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.

Summary of complaints From October 2017 to October 2018 there were 27 complaints about services for children and young people. The trust took an average of 35 days to investigate and close complaints, and 29.6% of the complaints were closed within 25 days. This is not in line with their complaints policy, which states that more than 50% of complaints should be closed within 25 days. A table of complaint subjects can be found below. Number of Percentage of Core service complaints total complaints Clinical Treatment - Paediatrics 11 40.7% Patient Care including Nutrition/Hydration 5 18.5% Communications 2 7.4% Clinical Treatment - A&E 2 7.4% Appointments including delays and cancellations 1 3.7% Consent 1 3.7% Waiting Times 1 3.7% Values and Behaviours (Staff) 1 3.7% Clinical Treatment - Anaesthetics 1 3.7% Admission, Discharge and Transfers 1 3.7% Access to Treatment or Drugs 1 3.7% Total 27 100.0%

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(Source: Routine Provider Information Request (RPIR) – Complaints tab)

Number of compliments made to the trust From October 2017 to September 2018 there were 10 compliments within services for children and young people. A breakdown by ward can be found below. Percentage of Number of Ward name/area total compliments compliments Jenny Lind Outpatients 4 60.0% Neonatal Intensive Care Unit 2 20.0% Children's Assessment Unit 2 20.0% Buxton Ward 2 20.0% Total 10 100.0% (Source: Routine Provider Information Request (RPIR) – Compliments tab) Senior managers told us the complaints process had been reviewed to make it more streamlined and reduce unnecessary response times. The results of this were unavailable at the time of our inspection. The matron told us the main theme of complaints was communication, such as parents not being updated on theatre delays. This was not in line with information submitted to us by the trust which indicated that communication made up 7.4% of all complaints. We saw leaflets on how to raise complaints, however these were not child friendly and we were told that child friendly leaflets did not exist. The complaints process started with complaints being received by the patient advice and liaison service (PALS) who then forwarded them on to the matron for investigation. Lessons learned were shared by the matron to ward managers and then to staff at ward meetings, with individuals receiving feedback. Staff could access the complaints policy on intranet when asked.

Is the service well-led? Leadership Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care. The children and young people’s service was part of the women and children’s division and was led by a divisional nursing director, a medical chief of division and a divisional operations manager. The service had its own matron who supported the ward managers. There were ward managers in place for the neonatal unit (NNU), Buxton ward and a manager for the children’s assessment unit (CAU), the day ward and the outpatients’ department. CAU staff told us they felt supported by the CAU/DPU/OPD manager. Staff told us they felt well supported by the newly recruited mental health matron. Several staff told us that since our last inspection, they felt more listened to and supported, especially by the new chief nurse. Both the divisional director and chief nursing officer were visible presences on NNU. On Buxton ward, staff told us the head of nursing was very supportive, as well as the chief nurse who was “engaging, visible and driven”. This was an improvement from our

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 298 previous inspection where staff told us they rarely or never saw the director of nursing or the executive team. There was now senior nurse management at weekends. This was an improvement from our previous inspection where staff told us that there was a lack of out-of-hours management support.

Vision and strategy The trust had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups representing the local community. The service had a detailed strategy going forward that included strategic aims and objectives. Staff could discuss the planned changes and improvements for their individual areas of work. This was reflected in what senior managers told us about planned changes for the future of the service, and in the strategy. This included the enhancement and improvement of high dependency nursing care and bed provision, and the improvement and unification of the service with children’s emergency care. However, whilst the unification with children’s emergency care was listed on the service’s risk register, the requirement and aim for more high dependency beds was not.

Culture Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. However, there was a poor culture around recurring themes of improvement not being addressed. Several safety concerns found in our previous inspection were still apparent. These included the fridge temperature checking, medicines related incidents, resuscitation trolley and defibrillator daily checks. These issues have been identified in all three of our inspections of this service since November 2015. This meant there was a poor culture around addressing safety concerns. Cultural problems were identified on the neonatal unit by senior managers in the six months leading up to our inspection. The Care Quality Commission had received whistle blowing concerns around staff having to cover other areas of the service that they did not feel equipped to do. Senior managers told us that senior nurses and the practice development nurse had worked with staff to ascertain additional competencies and skill mix, and tackle issues. Drop in sessions had been held with the head of nursing, and a cultural survey was due to be undertaken. A programme was planned to ensure that all nurses were aware of basic skills in both paediatrics and neonatal care. A ward manager told us that they felt communication and culture were improving, and that this improvement had been supported by monthly senior nurse meetings. A member of staff on the neonatal unit told us they felt well supported by colleagues and that there was good team work. They also told us they felt stressed and burnt out due to a lack of enough qualified in-service nurses. The majority of staff we spoke with told us that there was a feel of family amongst colleagues. On the children’s assessment unit, we saw a team achievements newsletter produced by the manager. This included congratulations on team marriages, births, and completion of competency skills. We saw a ‘team member of the week’ display board on Buxton ward.

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Most staff we spoke with said they felt proud of the flexibility of staffing, and gave examples where they had flexed to support other areas of the service when required. This was reflected by the senior leadership who acknowledged the same.

Governance The trust was not continually improving the quality of its services nor safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish. The children’s board meetings were held once every three months. The meetings were ceased in July 2018 to establish new terms of reference. The meetings recommenced in November 2018, which was the only current set of minutes we could review. Out of 31 members providing representation across different departments, safeguarding and different staff groups, 13 attended the November 2018 meeting. We were unable to assess whether representation was appropriate due to this being the first meeting since the amended terms of reference. Agenda items included patient experience matters, incidents, information governance, risk, quality and standards, workforce and productivity and performance. The set of minutes we could review did not show appropriate scrutiny of information. This was because some reports, such as the complaints report, were not submitted for review. A risk and incident report was submitted but was not scrutinised as the attendees discussed the report format and usefulness instead. We reviewed children’s board minutes from the time before the new terms of reference were set, in May and July 2018. We saw that reports were submitted to the meeting such as risk and complaints reports. However, there was no reporting of scrutiny or discussion and learning around these reports. Therefore, we were not assured of the effectiveness of this meeting in monitoring and managing governance processes for the service. We reviewed minutes of the neonatal intensive care unit communication meeting. Topics discussed included staffing and rotas and attendance was multidisciplinary. However, we found that required actions from these meetings were not taken forward, no actions had timeframes or named people to take responsibility.

Management of risk, issues and performance The trust did not have effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. Senior managers told us that the service’s main risks were staffing establishment, capacity and storage, lack of side rooms, high dependency care and gaps in the tier one and tier two rotas for medical staffing. The risk register did not reflect all the risks identified on our inspection. For example, the inconsistent checks of resuscitation equipment and children being admitted onto non-paediatric wards where staff were not always appropriately trained in safeguarding or paediatric resuscitation. This was found on our previous inspection also. Audits around self-harm and eating disorders were a part of the service’s audit plan. At the time of our inspection, one of these audits was in progress and the other one was waiting for its results to

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 300 be ratified. Whilst we could not assess the results of these audits, we were assured that the service was monitoring its outcomes around these areas. No risks or concerns around the provision of mental health care and support were found on inspection, and the service risk register did not identify any risks. When we reviewed the records of a patient with acute mental health needs we found that staff had appropriately risk assessed and escalated care to the relevant team. The mental health matron provided support to nursing staff on the care, treatment and support of patients’ mental health and emotional needs. The mental health liaison team also provided a range of training to ensure staff were confident and competent to care for patients alongside the child and adolescent mental health service.

Information management The trust collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards. There were plans in place to secure an electronic observation recording system for clinical areas. The electronic discharge letter was comprehensive and could be completed simultaneous to each patient being reviewed on ward rounds, using a computer-on-wheels. The service used a range of information systems in the day to day management of care. These included paper medical records, electronic and paper prescribing, and an electronic patient administration system that enabled staff to see where patients were admitted to and when as well as the location of medical records. Staffing rotas were electronic as were nursing dashboards. The service matron was responsible for cascading information upwards to the senior management team and downwards to the clinicians and other staff on the front line.

Engagement The trust engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively. Staff on the children’s day surgery unit told us that their input had been sought when a standard operating procedure was created for areas of escalation affecting their working areas. Staff throughout the service were aware of improvement plans for their areas of work and felt well informed. This demonstrates that staff opinions are sought for service improvements. Parents and carers were involved in the creation of peer groups on both the neonatal unit and Buxton ward, and were involved in the planning of services around individual children’s experiences. This demonstrates how patients and their families were involved and facilitated to be champions of their own care. We saw displays throughout the service of feedback from patients. The service used a communication feedback tool called ‘Tops and Pants’ that demonstrated positive feedback as well as feedback that required action. Tops and Pants feedback was incorporated into the service strategy.

Learning, continuous improvement and innovation

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The trust was committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation. Two senior nurses were involved in a study about improving care for children with complex needs and their carers. This led to five sessions being run for nursing staff, allied health professional staff, such as physiotherapists and dieticians, and medical staff to increase their confidence in supporting these children and their families. Paediatric research was promoted on the children’s assessment unit. A display board showed patients and families the names of the paediatric research team and their contact details. Nine separate studies and their consultant leads were displayed on the unit. Several clinical research trials were being undertaken on the neonatal unit. These included studies looking at breastmilk fortification, platelet transfusion and stool proteins.

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Outpatients

Facts and data about this service Total number of first and follow up appointments compared to England The trust had 788,922 first and follow up outpatient appointments from August 2017 to July 2018. The graph below represents how this compares to other trusts.

(Source: Hospital Episode Statistics - HES Outpatients)

Number of appointments by site The following table shows the number of outpatient appointments by site, a total for the trust and the total for England, from August 2017 to July 2018. Site Name Number of spells Norfolk and Norwich University Hospital 992,032 Cromer Hospital 63,782 Norfolk and Norwich University Hospitals NHS Foundation Trust 17,070 (Unspecified site) Norwich Community Hospital 12,072 The Roundwell Medical Centre 3,165 This Trust 1,097,552 England 107,320,812 (Source: Hospital Episode Statistics) 20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 303

Type of appointments The chart below shows the percentage breakdown of the type of outpatient appointments from August 2017 to July 2018. The percentage of these appointments by type can be found in the chart below:

Number of appointments at Norfolk and Norwich University Hospitals NHS Foundation Trust from August 2017 to July 2018 by site and type of appointment.

Note: appointments assigned to ‘Norfolk and Norwich University Hospitals NHS Foundation Trust’ are where a site was unspecified within the raw data. The total appointments at the trust are assigned to ‘This Trust’. (Source: Hospital Episode Statistics) Norfolk and Norwich University NHS Foundation Trust provides outpatient services from two locations, Norfolk and Norwich Hospital and Cromer Hospital. We did not inspect Cromer Hospital during this inspection. The trust had 788,922 first and follow up outpatient appointments from August 2017 to July 2018. Outpatient services are provided for a wide range of specialties including anti-coagulant/venous thromboembolism (VTE), audiology, cardiology, gastroenterology, respiratory, rheumatology, paediatrics, ophthalmology, physiotherapy, general surgery, ear, nose and throat (ENT), oncology, dermatology, diabetes, trauma and orthopaedics, neurology, general medicine, and urology. Outpatient services are managed within all four of the hospital’s divisions, dependent on their specialty. Outpatient appointments are available Monday to Friday, with occasional evening and weekend clinics dependent on speciality, capacity and need. Throughout our inspection we visited eight of the outpatient areas managed throughout the divisions. We used a variety of methods to help us gather evidence to assess and judge the outpatient services. We spoke with eight patients and those important to them, four doctors, 18 registered nurses, three health care assistants (HCAs), three allied healthcare professionals, and three administration support staff. Members of the inspection team interviewed the clinical leads for the Medical and Surgery Divisions, as these are the divisions under which most outpatient services sit. We observed the care and the environment and we looked at seven sets of patient

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 304 records. We also looked at a wide range of documents, including policies, minutes of meetings, action plans, risk assessments, and audit results. We last inspected this service in September 2017 and rated Outpatients as Requires Improvement overall. We rated safe, responsive, and well led as requires improvement and caring as good. We do not currently rate the effectiveness of outpatient services.

Is the service safe? By safe, we mean people are protected from abuse* and avoidable harm. *Abuse can be physical, sexual, mental or psychological, financial, neglect, institutional or discriminatory abuse. Mandatory training The service provided mandatory training in key skills to all staff and made sure the majority of staff completed it. Staff said access to face to face training was sometimes difficult to access.

Mandatory training completion rates The trust set a target of 90% for completion of mandatory training.

Trust level A breakdown of compliance for mandatory training courses as at September 2018 at trust level for qualified nursing staff in outpatients is shown below:

Number Number of of staff eligible trained staff Completion Trust Met Name of course (YTD) (YTD) rate Target (Yes/No) Blood Transfusion 3 3 100.0% 90% Yes Health and Safety (Slips, Trips and Falls) 96 98 98.0% 90% Yes Infection Prevention (Level 2) 93 98 94.9% 90% Yes Fire Safety 91 98 92.9% 90% Yes Medicine management training 85 95 89.5% 90% No Adult Basic Life Support 79 90 87.8% 90% No Equality and Diversity 85 98 86.7% 90% No Clinical Record Keeping 84 98 85.7% 90% No Venous Thromboembolism 73 86 84.9% 90% No Information Governance 82 98 83.7% 90% No Resuscitation 20 24 83.3% 90% No Manual Handling - People 80 98 81.6% 90% No

In outpatients the 90% target was met for four of the 12 mandatory training modules for which qualified nursing staff were eligible. Medical staff reside within the other specialties within the trust's information systems and therefore the trust was unable to provide us with medical staffing information for outpatients. However, the trust was able to provide oversight of medical staff under the specialities for each related core service. 20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 305

Norfolk and Norwich University Hospital A breakdown of compliance for mandatory training courses at September 2018 at Norfolk and Norwich University Hospital for qualified nursing staff in outpatients is shown below:

Number Number of of staff eligible trained staff Completion Trust Met Name of course (YTD) (YTD) rate Target (Yes/No) Blood Transfusion 2 2 100.0% 90% Yes Health and Safety (Slips, Trips and Falls) 77 79 97.5% 90% Yes Infection Prevention (Level 2) 76 79 96.2% 90% Yes Fire Safety 72 79 91.1% 90% Yes Medicine management training 68 76 89.5% 90% No Resuscitation 14 16 87.5% 90% No Manual Handling - People 68 79 86.1% 90% No Equality and Diversity 68 79 86.1% 90% No Clinical Record Keeping 67 79 84.8% 90% No Adult Basic Life Support 60 71 84.5% 90% No Venous Thromboembolism 61 73 83.6% 90% No Information Governance 66 79 83.5% 90% No

At Norfolk and Norwich University Hospital the 90% target was met for four of the 12 mandatory training modules for which qualified nursing staff were eligible.

Cromer Hospital A breakdown of compliance for mandatory training courses at September 2018 at Cromer Hospital for qualified nursing staff in outpatients is shown below:

Number Number of of staff eligible trained staff Completion Trust Met Name of course (YTD) (YTD) rate Target (Yes/No) Adult Basic Life Support 19 19 100.0% 90% Yes Fire Safety 19 19 100.0% 90% Yes Blood Transfusion 1 1 100.0% 90% Yes Health and Safety (Slips, Trips and Falls) 19 19 100.0% 90% Yes Venous Thromboembolism 12 13 92.3% 90% Yes Clinical Record Keeping 17 19 89.5% 90% No Medicine management training 17 19 89.5% 90% No Equality and Diversity 17 19 89.5% 90% No Infection Prevention (Level 2) 17 19 89.5% 90% No Information Governance 16 19 84.2% 90% No Resuscitation 6 8 75.0% 90% No Manual Handling - People 12 19 63.2% 90% No

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At Cromer Hospital the 90% target was met for five of the 12 mandatory training modules for which qualified nursing staff were eligible. (Source: Routine Provider Information Request (RPIR) – Training tab) Throughout our inspection, most of the nursing, medical and health care assistant staff we spoke with told us they could access mandatory training and that training opportunities were good. However, staff said access to face to face training was sometimes difficult to access or cancelled due to operational pressures on the service, for example manual handling and resuscitation training. Training was delivered through a mix of e-learning packages, and face-to-face classroom sessions. Levels of mandatory training for nursing staff has shown a marginal improvement since our last inspection.

Safeguarding Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.

Safeguarding training completion rates The trust set a target of 90% for completion of safeguarding training.

Trust level A breakdown of compliance for safeguarding training courses as at September 2018 at trust level for qualified nursing staff in outpatients is shown below: Number of staff Number of trained eligible Completion Trust Met Name of course (YTD) staff (YTD) rate Target (Yes/No) Safeguarding Children (Level 2) 97 98 99.0% 90% Yes Safeguarding Adults (Level 2) 96 98 98.0% 90% Yes PREVENT - Level 3 93 96 96.9% 90% Yes

In outpatients the 90% target was met for all three of the safeguarding training modules for which qualified nursing staff were eligible. Medical staff reside within the other specialties within the trust's information systems and therefore the trust was unable to provide us with medical staffing information for outpatients. However, the trust was able to provide oversight of medical staff under the specialities for each related core service. Norfolk and Norwich University Hospital A breakdown of compliance for safeguarding training courses at September 2018 at Norfolk and Norwich University Hospital for qualified nursing staff in outpatients is shown below: Number of staff Number of trained eligible Completion Trust Met Name of course (YTD) staff (YTD) rate Target (Yes/No) 20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 307

Safeguarding Children (Level 2) 78 79 98.7% 90% Yes Safeguarding Adults (Level 2) 77 79 97.5% 90% Yes PREVENT - Level 3 75 77 97.4% 90% Yes

At Norfolk and Norwich University Hospital the 90% target was met for all three safeguarding training modules for which qualified nursing staff were eligible.

Cromer Hospital A breakdown of compliance for safeguarding training courses at September 2018 at Cromer Hospital for qualified nursing staff in outpatients is shown below: Number of staff Number of trained eligible Completion Trust Met Name of course (YTD) staff (YTD) rate Target (Yes/No) Safeguarding Children (Level 2) 19 19 100.0% 90% Yes Safeguarding Adults (Level 2) 19 19 100.0% 90% Yes PREVENT - Level 3 18 19 94.7% 90% Yes

At Cromer Hospital the 90% target was met for all three safeguarding training modules for which qualified nursing staff were eligible. (Source: Routine Provider Information Request (RPIR) – Training tab) The hospital had policies in place regarding safeguarding of adults, and staff could access National Institute for Health and Care Excellence (NICE) guidance on identifying domestic violence and female genital mutilation (FGM). Staff accessed these policies through the trust’s intranet system. Safeguarding training completion rates were similar to our past inspection. We requested the data for the number of children under the age of 18 that were seen as outpatients in 2018 outside of the Jenny Lind children’s outpatient department, but the trust was not able to provide the data as this was not currently recorded. Nursing staff in the outpatient areas we visited were undertaking activities which would necessitate level three safeguarding training to be undertaken. For example, in ophthalmology, nurses were involved in administering diagnostic eye drops to children. Staff compliance with Safeguarding Children level 3 met the trust target. At the time of our inspection we requested details of the number of outpatient staff that were required to undertake take level three safeguarding training. The trust identified 122 staff that required the training and 116 had completed it. A compliance figure of 95.1%. All nursing staff we spoke with understood their responsibilities in terms of safeguarding adults and children. They could tell us how they would report a safeguarding concern and what they would report. One member of nursing staff told us they had recently raised a safeguarding concern regarding an older person’s support in the community and received feedback from safeguarding team on the referral. The trust had a designated safeguarding team for adults and for children. Staff we spoke could describe how they would contact the safeguarding team for advice and guidance if required. There was a joint trust Guideline for the management of children who did not attend outpatients or children’s assessment unit or leave accident and emergency before being seen, which set out the steps to be taken when a child did not attend an appointment. This stated that “When children do not attend for planned care the case notes must be reviewed by a consultant or specialist

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 308 registrar. The risk to the child will be assessed. Primary care will be informed.” Staff were aware of the guidelines for following up and referring concerns when a child did not attend an appointment.

Cleanliness, infection control and hygiene The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection. The trust had an infection control policy, which was accessible to all staff on the trust’s intranet system including agency and locum staff. All clinical areas we visited were visibly clean. Nursing and medical staff adhered to the trust hand hygiene and ‘bare below the elbow’ policy, and wore personal protective equipment (PPE) such as gloves and aprons when undertaking personal care. Staff adhered to the hand hygiene policy and ensured that their hands were decontaminated before and after contact with patients. They also used hand sanitiser where appropriate. This was in line with National Institute for Health and Care Excellence (NICE) Quality Standard 61, which states that healthcare workers should decontaminate their hands immediately before and after every episode of direct contact care. This was also in line with the World Health Organisation’s ‘five moments for hand hygiene’. These guidelines are for all staff working within healthcare environments and define the key moments when staff should be performing hand hygiene to reduce risk of cross contamination between patients. Hand sanitiser was available at the entrance to clinic rooms and outpatient areas and clear signage was in place asking all staff and visitors to use hand sanitiser to prevent, protect, and control the spread of infection when entering or leaving outpatient areas. Commode and bed pan audits were carried out on a monthly basis in outpatient areas up to October 2018. In October 2018 the trust moved to three monthly audits to bring them in line with hand hygiene audits. Commode and bed pan audits showed a high level of compliance, with all areas averaging 100%. Results from the most recent monthly hand hygiene and ward cleanliness audits were displayed in all outpatient areas we visited. We saw evidence that re-audits were carried out within the same month if concerns had been identified. Hand hygiene audits for January 2018 to December 2018 showed all outpatient areas met the trust compliance target of 95% for all months audited. All the equipment we checked was visibly clean and displayed green ‘I am clean’ stickers with the date of cleaning to identify those cleaned and ready for use. The trust audited the cleanliness of the outpatient environment. We saw evidence that re-audits were carried out within the same month if concerns had been identified. Audits for January 2018 to December 2018 showed all outpatient areas met the trust compliance target of 95% for all months audited. All outpatient children’s play areas and toys were visibly clean in the areas we inspected. Domestic staff completed checklists to evidence that play areas were tidied and safety checked each day a clinic was running. Cleaning of toys took place once a week. We reviewed checklists for the previous four months and found staff completed them in line with trust policy.

Environment and equipment Equipment was not consistently serviced in line with manufacturers guidelines. Premises were suitable for their intended use.

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The clinical and patient waiting areas we visited were bright, well organised, and free from clutter. We looked at 30 pieces of equipment including airflow blood pressure monitors, hoists and patient monitoring equipment. We requested a maintenance and testing schedule for all outpatient equipment at the time of our inspection. The trust provided detailed lists of equipment from oral health, physiotherapy, and ophthalmology. The lists provided by the trust showed a lack of oversight of equipment preventative maintenance in ophthalmology, with 69 out of 177 pieces of equipment outside the recommended preventative service period. The trust had identified that medical devices have previously missed their planned preventative maintenance schedule due to the inability to either locate the device, or the device was in use. The trust reported this had resulted in the equipment remaining in use despite exceeding its service date. This issue was raised at our previous inspection. The trust had produced a Standard Operating Procedure (SOP) for the Management of Medical Equipment as a result of our past inspection, which was due for approval in February 2019. The new SOP was intended to ensure that all medical devices used within the trust are maintained in line with the manufacturer’s recommendations. Resuscitation equipment was visibly clean and stored in an accessible location on all the wards we visited. We reviewed a sample of consumable equipment, and 16 oxygen cylinders and found they were all within calibration and maintenance dates. However, in the Oncology & Haematology outpatient’s area we discovered two oxygen canisters that were not secured and were therefore accessible to members of the public. This was raised with the service manager who arranged for correct storage of the canisters. We reviewed records of safety checks for resuscitation equipment from November 2018 to the date of our inspection, which showed staff had completed daily checks on all areas we visited. We inspected the storage and expiry dates of consumable items, for example syringes, personal protective equipment and catheters in all the areas we visited. All consumables we looked at were stored correctly and were within expiry dates in all outpatient areas. Patient trolleys, equipment, and curtains providing privacy, were visibly clean throughout the outpatient areas. Disposable curtains displayed an expiry check date and we found all curtains to be within service date and in good condition. All outpatient waiting areas displayed signage to identify the nurse in charge, the number of staff planned and actual staff on duty. Signage was clear and enabled staff, patients and relatives to see the number of staff on duty, identify staff roles, and see who oversaw each outpatient clinic. Staff in all areas complied with DH Health Technical Memorandum (HTM) 07/01 in relation to the Safe Management and Disposal of Healthcare Waste (2013). This meant staff segregated waste by type using appropriate colour-coded bags and stored them in secure areas. Waste bins were colour coded for the appropriate waste disposal method and we noted that domestic staff routinely emptied waste bins during our inspection. Nursing staff correctly labelled and secured sharps bins. We inspected sharps bins in each of the outpatient areas we visited and saw that staff did not overfill any of the sharps bins. All cleaning cupboards were kept locked when not in use and storage of cleaning materials met Control of Substances Hazardous to Health (COSHH) regulations 2002.

Assessing and responding to patient risk Staff completed and updated risk assessments for each patient. They kept clear records and asked for support when necessary.

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The trust had an appropriate process for assessing and responding to risk for patients waiting on the waiting list. Consultants reviewed all patient referrals to allocate clinical priority within two working days of receipt. Cases which had not been reviewed within five working days were escalated to the weekly patient tracking list (PTL) meeting. Patients whose condition was deemed urgent would be seen and treated within a shorter timescale and in priority over those whose condition was more routine in nature. A weekly patient tracking list meeting was held, at which patients waiting over 18 weeks were discussed, along with the reasons why treatment had not commenced. Clinical urgency was reviewed and capacity issues highlighted. Every patient who had waited 40 weeks or more had their pathways managed individually at the PTL meeting to ensure patients were treated as soon as possible. All patients on a cancer pathway were also reviewed, and patients waiting over 62 days and 104 days were discussed in detail, along with the reasons why treatment had not commenced. There were processes in place for the assessment of people within outpatient clinics who were clinically unwell and required hospital admission. Staff could describe these processes. An audit of the World Health Organisation (WHO) and five steps to safer surgery checklist had been carried out in outpatient cardiology, dermatology and endoscopy at the hospital in the 12 months before our inspection. Audits included a review of documentation and observation. Results of the audits showed a high rate of compliance in endoscopy and dermatology. However, results for cardiology were inconsistent. For example, the patient preparation checklist had all sections completed in 25% of cases and catheter lab checklist had all sections completed in 22% of cases, but the proof of handover having a signature for recovery transfer nurse was completed in 88% of cases. Overall, the audit results had improved from the previous cardiology WHO checklist audit. Local safety standards for invasive procedures (LocSSIP’s) were in place in outpatient areas we visited. We requested a copy the completed audits for 2018 and the audit plan for 2019.The trust provided copies of LocSSIP’s audits for the Speech and Language therapy service, ENT, and neurology. The audits showed satisfactory level of compliance across the three audits. However, the trust did not provide a copy if their audit plan for 2019. Therefore, we could not be assured the trust had oversight of the LocSSIP’s audit plan moving forward. Risk assessments had been appropriately carried out in all the seven patient records that we reviewed during our inspection.

Nurse staffing The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.

Overall staffing rates The trust has reported their staffing numbers at March 2018 and at September 2018 for qualified nursing staff in outpatients. As at September 2018, the trust was close to establishment for qualified nursing staff in outpatients with a fill rate of 94.8%.

As at March 2018 As at September 2018 Actual Planned Actual Planned staff – staff – Fill staff – staff – Fill Site WTE WTE rate WTE WTE rate Cromer Hospital 7.9 7.9 100.0% 7.9 7.9 100.0%

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Norfolk and Norwich University Hospital 57.2 64.1 89.2% 59.3 63.0 94.1% Trust wide 65.1 72.0 90.4% 67.2 70.9 94.8%

(Source: Routine Provider Information Request (RPIR) –Total staffing tab)

Vacancy rates From September 2017 to August 2018, the trust reported a vacancy rate of 8.7% for qualified nursing staff in outpatients. The trust does not have a target for vacancy rate. A breakdown by site can be found below. • Norfolk and Norwich University Hospital: 9.4% • Cromer Hospital: 3.0% (Source: Routine Provider Information Request (RPIR) – Vacancy tab)

Turnover rates From October 2017 to September 2018, the trust reported a turnover rate of 10.3% for qualified nursing staff in outpatients. This was greater than the trust target of 10.0%. A breakdown by site can be found below. • Norfolk and Norwich University Hospital: 10.9% • Cromer Hospital: 7.5% (Source: Routine Provider Information Request (RPIR) – Turnover tab)

Sickness rates From September 2017 to August 2018, the trust reported a sickness rate of 5.3% for qualified nursing staff in outpatients. This was greater than the trust target of 3.5%. A breakdown by site can be found below. • Norfolk and Norwich University Hospital: 5.7% • Cromer Hospital: 3.2% (Source: Routine Provider Information Request (RPIR) – Sickness tab)

Bank and agency staff usage From September 2017 to August 2018, the trust reported that 6,277 of the 295,415 establishment hours were filled by bank staff (2.1%) and 35 hours were filled by agency staff (<0.1%). There were 21,083 hours that needed to be covered by bank or agency that were unfilled (7.1%). A breakdown of bank and agency usage by staff type is shown below: Total establishment Staff type Bank hours Agency hours Unfilled hours hours Qualified 775 (0.5%) 35 (<0.1%) 9,510 (6.7%) 141,014 Non-qualified 5,502 (3.6%) 0 11,573 (7.5%) 154,400 Total 6,277 (2.1%) 35 (<0.1%) 21,083 (7.1%) 295,415

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(Source: Routine Provider Information Request (RPIR) - Nursing bank agency) There are no national accepted standards or guidelines for how outpatient clinics should be staffed. The number of staff required in outpatient areas changed from day to day dependent on the number of clinics running that day. Senior nurses told us that clinics were rarely cancelled due to staffing shortages as nursing staff were flexible to ensure they provided cover for each clinic. Senior staff would adjust the number and skill mix of nursing staff covering clinics as necessary. We requested data for the number of clinics that had been cancelled in 2018 due to insufficient staff, but the trust was unable to provide this data. Bank staff were utilised across the outpatient areas to cover any shortfalls in staffing numbers. Senior nurses told us that bank staff were normally regular staff who knew the outpatient area where they were working. There had been significant focus trust wide in reducing reliance on temporary and agency staff, which had been supported through recruitment in substantive staff and incentives for joining the bank. Specialist and senior nurses led their own clinics in outpatient areas. Nurse consultants were also employed in outpatient areas. Staff told us registered children’s nurses in the Jenny Lind outpatients department were available to support and advise staff when required.

Medical staffing Medical staffing was provided by the relevant clinical specialty running the clinics in the outpatient department. Medical staff in outpatient clinics were of mixed grades, ranging from consultants to junior doctors. Medical staff on the inspection did not raise any concerns regarding staffing levels and cover for outpatient clinics. The trust was unable to provide a breakdown of overall staffing hours, vacancy rates, turnover rates, sickness rates, or bank and locum staff use at an outpatient level. Data regarding medical staffing is reported under the relevant core service report for each service. We were not able to gain assurance that the trust could monitor medical staffing in outpatient areas and identify if there were concerns, for example in medical staff sickness in outpatients.

Records Storage of records for patients waiting for consultation was not always secure. Staff kept appropriate records of patients’ care and treatment. Records were clear, up-to-date and available to all staff providing care. The trust used mainly paper records, with some electronic access to documents. Paper records were delivered from the health records library by a shuttle service. Records were transported in locked cages for security. Staff told us that they would request notes from the health records library when patients booked their appointment but that they could also request urgent notes by telephone, and that these would be included to the next hourly shuttle. The trust had a long-term strategy for an electronic patient record to be implemented and was continuing to trial and review options. Medical and nursing staff confirmed that they almost always had access to full medical records. Staff told us that when notes were not available for a patient’s appointment, they would print off the information held electronically, which would include any internal electronic letters and results. There was a tracking system available to assist staff with finding the location of a record.

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Within the ophthalmology, ear, nose and throat (ENT), and dermatology outpatient clinics, patient notes were left outside consultation rooms on shelves which were accessible to the public. Laminated ‘no entry’ cards were placed on top of notes to dissuade unauthorised access but security of notes was not robust and they could be accessed by anyone. This concern was also identified at our two previous inspections. Staff indicated that the risk of unauthorised access to records was mitigated by staff being in the corridors at most times. The senior sister in ophthalmology told us the purpose of storing the notes outside consultation rooms was so staff could observe if any of the clinics were being delayed and therefore offer assistance, because the result would be a build-up of patient notes outside the consultation room. We reviewed seven patient records and found that they were all in a good condition, with legible entries and in chronological order. There was evidence that the notes had been available for clinic and discussions in the outpatient department had been recorded. We requested evidence of record audits being carried out in outpatient areas. The trust provided audit results from August 2018 to December 2018. The most recent audit results for 22 outpatient areas from December 2018 showed 20 areas rated good and 2 areas rated outstanding for clinical documentation. We also requested data on the percentage of medical records that were not available when required for outpatient appointments in 2018. However, the trust was unable to provide the data requested. Staff told us that quality assurance audits that had been carried out in outpatient areas, which included questions about the quality of entries into patient notes, whether confidentiality was maintained, and assessing staff knowledge of information governance. We requested details of the results of quality assurance audits for outpatient areas at the time of our inspection. The trust provided the most recent audits, which included outpatient imaging, medical illustration, and phlebotomy. The audits provided by the trust did not include results of audits of patient records, because they were not applicable to the specialities included. The trust did not have a specific key performance indicator for letters going out to GPs. We requested data for the time taken for letters to go out to GPs, but the trust did not provide the requested information.

Medicines The service did not follow best practice when recording and storing medicines. However, patients received the right medication at the right time. Medicines were not always stored appropriately in outpatient areas. In the dermatology and ENT outpatient areas room temperature checks were not being carried out in medication storage rooms. The medications that were being stored in these rooms included those which should not be stored above 25 degrees Celsius. The trust had arranged for thermometers and recording books to be placed in the rooms since our last inspection when this issue was raised, but they were not routinely being used by staff. This meant that staff could not be assured that the quality of these medications had been maintained. The clean utility room, which was used for storing medicines, in Dermatology was being used by staff to make hot drinks, which meant the room was accessible to non-clinical staff. The key for the medicine storage cupboard was being stored in a drawer in the room, which meant it was accessible to all staff that entered the room. The Oncology & Haematology outpatient area also had a controlled drug storage safe that had not been checked since September 2017, which contained a controlled drug. This was raised with the matron who said that the reason the controlled drugs had not been checked was, because they

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 314 were rarely used. The Matron arranged for the controlled drug and storage to be removed at the time of the inspection. All other medications we checked were within date and correctly stored. Medicine fridge temperatures were checked daily in all areas and correctly recorded according to trust policy. In ENT and ophthalmology staff booked out prescription books to a specific clinic or room at the start of each day. However, there was no process for collating or auditing sheets to record how many sheets had been used in each clinic. Therefore, staff could not assure themselves that sheets had not been removed against trust policy. The pharmacy service was available Monday to Friday from 8am to 5:45pm, Saturday from 9am to 1pm, and Sunday from 10am to 12pm. Outpatients were served by an in-house pharmacy team. The pharmacy department supported on-going care of patients after an outpatient appointment, often through the use of homecare companies. The pharmacy service could provide a medicines counselling service to all outpatients on request. Patient information leaflets were included in all medication to take outside of the trust. The pharmacy’s target time for dispensing take home medications was 45 minutes and this was achieved in 92.5% of cases between July 2018 and the end of December 2018. We reviewed seven patient records and found that allergies had been recorded appropriately on all the records where this was applicable. The trust conducted annual medicine audits for outpatient areas across the trust providing a rating of inadequate, requires improvement, good, or outstanding in each area. Where the rating was good or outstanding, a re-audit would be conducted within 12 months, a requires improvement rating would result in a six monthly, and an inadequate rating would result in a re-audit after three months. The trust provided the previous 12 months of audits at the time of our inspection. The trust internal audits rated two areas inadequate, seven areas requires improvement, six areas good, and six areas outstanding. The trust identified areas of concern across the outpatient service, which included ambient temperature checks, closing and locking medicine room doors and medicine cupboards. Improvements had not been embedded at the time of our inspection.

Incidents The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.

Never Events Never events are serious incidents that are entirely preventable as guidance, or safety recommendations providing strong systemic protective barriers, are available at a national level, and should have been implemented by all healthcare providers. From November 2017 to October 2018, the trust reported no incidents classified as a never event for outpatients. (Source: Strategic Executive Information System (STEIS))

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Breakdown of serious incidents reported to STEIS In accordance with the Serious Incident Framework 2015, the trust reported five serious incidents (SIs) in outpatients which met the reporting criteria set by NHS England from November 2017 to October 2018. The breakdown by incident type was as follows: • Treatment delay meeting SI criteria with three (60% of total incidents). • Slips/trips/falls meeting SI criteria with one (20% of total incidents). • Diagnostic incident including delay meeting SI criteria (including failure to act on test results) with one (20% of total incidents). (Source: Strategic Executive Information System (STEIS)) We reviewed root cause analysis (RCA) investigation reports for three serious incidents that related to outpatient areas. Investigations included a detailed review of events. A number of changes to practice were identified as a result of the investigations, which had been added to an action plan with timescales and persons responsible assigned to each action. For example, a new process for monitoring and recording that patients are informed of their results in urology was enacted. In ophthalmology, a “High Impact Intervention” plan had been created to help reduce the backlog in follow up appointments for patients that had resulted in patient’s vision deteriorating between appointments. There was limited evidence of the involvement of patients and relatives in investigations, although they were informed that the investigations were taking place and were updated on the outcome of the investigation. Staff confirmed that learning from incidents was shared through team meetings and newsletters. Staff could describe incidents that had occurred in their department. Staff could describe changes to practice as a result of incidents. However, several junior staff still said that they would go to a senior member of staff if an incident needed to be reported. The outpatients service had applied duty of candour on 10 occasions between January 2018 and December 2018. Duty of candour is a legal responsibility of care providers to inform patients and apologise when an error has occurred in their care that results in moderate or significant harm. Duty of candour should be carried out within 10 working days. Staff displayed an understanding of duty of candour and were able to give examples of times when duty of candour had been carried out. The trust had put in place a process to ensure that duty of candour was carried out within the appropriate time scale. Once it had been confirmed that an incident was of moderate harm or higher, an email was sent to the responsible clinician to request that duty of candour be met and indicating the date that it must be met by. The trust risk team tracked any incidents of moderate harm or higher to ensure there were no breaches. Any potential likely breaches were escalated to the chief of the division, divisional operational director, divisional nurse director and to the medical director. A one-off training session on duty of candour and the responsibilities of staff regarding this was delivered by the risk team during corporate induction.

Safety thermometer The Safety Thermometer is used to record the prevalence of patient harms and to provide immediate information and analysis for frontline teams to monitor their performance in delivering

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 316 harm free care. Measurement at the frontline is intended to focus attention on patient harms and their elimination. Data collection takes place one day each month – a suggested date for data collection is given but wards can change this. Data must be submitted within 10 days of suggested data collection date. Records the trust provided us with showed that a Safety Thermometer for outpatients was not in use. However, safety metrics were collected and reported through the nursing and new outpatient dashboard, which was launched on the same week as our inspection.

Is the service effective? Evidence-based care and treatment The service provided care and treatment based on national guidance and evidence of its effectiveness. The trust did not provide a copy of their audit action plan. The policies we reviewed in outpatient areas were aligned to National Institute for Health and Care Excellence (NICE) guidance. The trust had developed a process for the implementation of NICE guidance which involved the clinical audit and effectiveness manager reviewing all published NICE guidance each month. The responsible clinical lead would be contacted to review the guidance and assess relevance, conduct a gap analysis of current practice against the recommendations and identify shortfalls as required. The clinical lead was also responsible for ensuring the NICE guidance was discussed at relevant speciality governance meetings and that any provisional associated risks with any areas of non-compliance were agreed. The trust shared evidence of speciality governance meetings which showed national guidance was a standing item on agendas. There were treatment protocols and proformas available for staff reference in the outpatient areas we visited. All the protocols and proformas we reviewed were up to date and linked to evidence based guidance such as NICE. The use of protocols therefore promoted care being delivered in line with evidence based guidance. We requested the trust’s clinical audit plan for outpatients at the time of the inspection, but this was not provided by the trust. Staff told us that audits were not registered specifically by outpatient department but by specialty. Staff told us that the trust participated in relevant national audits in order to benefit from benchmarking and identification of service improvements and action plans were drawn up based on audit findings to implement improvements.

Nutrition and hydration Staff gave patients enough food and drink to meet their needs. Patients and relatives had access to drinking water machines in waiting areas. There were vending machines available throughout the hospital and both east and west sides had access to café facilities. There was also a main restaurant area on the ground floor of the central atrium. Staff told us that they would make arrangements to provide food and hot drinks for patients who had been in outpatient areas for an extended period of time. Quality assurance audits had been carried out in some outpatient areas and some of these included questions about meeting nutritional and hydration needs. Questions focused on whether patients had access to clean drinking water, whether snacks were provided for patients with extended appointments over four hours, whether there was a hot drinks dispenser close to the

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 317 department, and whether patients were assisted with eating where applicable. Audits showed departments audited were compliant with trusts policies on access to nutrition and hydration.

Pain relief Staff assessed and monitored patients regularly to see if they were in pain. They supported those unable to communicate using suitable assessment tools and gave additional pain relief to ease pain. Staff stated that any patients experiencing chronic pain would be referred to the pain management team. An outpatient pain management service, for adults with long term persistent pain, was based at another local provider. We reviewed seven outpatient records during our inspection and there was evidence of pain relief in the two records where this was applicable. We observed staff checking on patients’ pain and discomfort. All patients we spoke with told us that staff always asked about pain during clinic when relevant. Staff monitored patients’ pain using pain assessment tools. They had a visual chart ranging from zero to 10, zero being the least pain with a happy face and 10 the worst the pain could be with a very sad face. This was useful to use for children and patients with learning disabilities or for those with impaired communication skills.

Patient outcomes From August 2017 to July 2018 the follow-up to new rate for Norfolk and Norwich University Hospital was similar to the England average and the follow up to new rate for Cromer Hospital was higher than the England average.

Follow-up to new rate, Norfolk and Norwich University Hospitals NHS Foundation Trust.

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We requested data on waiting times within clinics and the proportion of clinics that started late but the trust confirmed that this data was not routinely completed in a large proportion of appointments and were therefore not able to provide this information. Staff told us that information about the outcomes of people's care and treatment was collected and monitored at specialty level. The trust participated in the Getting It Right First Time (GIRFT) programme, designed to improve medical care within the NHS by reducing unwarranted variations. GIRFT identifies changes that will help improve care and patient outcomes and the trust had action plans in place to address unwarranted variation that had been identified, for example for the utilisation of outpatients for diagnostic and therapeutic procedures.

Competent staff The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service. We requested up to date appraisal data at the time of our inspection. Data provided by the trust was not broken down by nursing or medical staff. The average compliance rate across outpatient areas in the trust was 84.9%. The highest rate of compliance was in Ear, Nose & Throat (ENT)/Oral Health at 100% and lowest performing area was older people’s medicine at 62.5%. Staff spoke positively about the opportunity for development and progression. Most senior staff we spoke to on the inspection had progressed up to their current role whilst working for the trust and had recently taken part on an internal leadership programme. The trust utilised link nurses in outpatient areas to offer support, guidance, and advice to staff on issues such as diabetes, dementia, and safeguarding, amongst others. Specialist nurses and nurse consultants were also working in outpatient areas, many of whom had specialist knowledge on specific topics, which meant they could provide support to other staff.

Multidisciplinary working Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care. Outpatient services were run by multidisciplinary teams. Nursing staff, healthcare assistants and doctors told us the teamwork and multidisciplinary working was effective in outpatient areas. For example, nursing staff provided positive feedback about the advice and support that had been provided by medical staff when required and staff in orthopaedics told us they worked closely with physiotherapy and occupational therapy staff to reduce the number of occasions patients had to visit the hospital for appointments. One stop clinics were available involving different disciplines of staff working together. For example, in cardiology specialist nurses held joint clinics with dieticians, occupational therapy and physiotherapy. There were also combined obstetric and cardiac clinics. A transition clinic was also held, where paediatric and adult cardiologists carried out a joint clinic to promote continuity of care for young people transitioning between children’s and adult services. The trust continued to hold quarterly outpatient forum meetings, which began in January 2017. We attended the forum that took place during out inspection and reviewed minutes from previous forums and saw that between 30 and 40 members of staff attended on average, who came from a

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 319 range of areas and a range of seniority levels. Staff felt that the forums allowed communication across divisions, grades, professions, and specialities. There were established links between outpatient staff and the learning disabilities and safeguarding teams. Staff described regularly accessing different teams for support.

Seven-day services Weekend and evening clinics had been arranged within the majority of areas we visited to help alleviate waiting lists. This offered appointment times which were more accessible for patients. The trust provided data on the number of weekend and evening clinics that had taken place in December 2018. Weekend and evening clinics had regularly taken place in general surgery, urology, ENT, ophthalmology, plastic surgery, paediatric surgery, cardiology and audiology.

Health promotion People who may require extra support whilst in clinic were identified through alerts on the patient record system. For example, alerts were available to identify patients who had a learning disability or were living with dementia. Staff said that these alerts would prompt them to provide additional support before and during the clinic visit, usually in liaison with link nurses or specialist teams. Smoking cessation and healthy eating was promoted throughout the outpatient areas we visited. Posters were displayed in waiting areas and leaflets were also available. We observed two consultations and saw that people were involved in the regular monitoring of their health and were empowered to manage their own health. Throughout the outpatient areas we visited, staff said that they would take the opportunity to undertake health promotion during consultations. For example, in ophthalmology staff would take the opportunity to talk with patients about smoking cessation and the effect it can have on eyesight and orthopaedics staff would discuss the need to be physically active to aid rehabilitation. The trust had an epilepsy specialist nursing team, who would develop a seizure care plan with patients and their family or carers when appropriate. The care plan documented how risks associated with the person’s seizure could be managed in order to effectively reduce risk of harm to the individual and promote independence.

Consent, Mental Capacity Act and Deprivation of Liberty Safeguards Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health.

Mental Capacity Act and Deprivation of Liberty training completion The trust set a target of 90% for completion of Mental Capacity Act (MCA) and Deprivation of Liberty training.

Trust level

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A breakdown of compliance for Mental Capacity Act (MCA) and Deprivation of Liberty Safeguarding (DoLS) courses at September 2018 for qualified nursing staff in outpatients is shown below: Number of staff Number of trained eligible Completion Trust Met Name of course (YTD) staff (YTD) rate Target (Yes/No) Mental Capacity Act Level 1 88 95 93% 90% Yes Deprivation of Liberty Safeguards 88 95 93% 90% Yes

Qualified nursing staff met the trust training target both of the training modules relating to the Mental Capacity Act (MCA) and Deprivation of Liberty (DoLS).

Norfolk and Norwich University Hospital A breakdown of compliance for Mental Capacity Act (MCA) and Deprivation of Liberty Safeguarding (DoLS) courses at September 2018 for qualified nursing staff in outpatients at Norfolk and Norwich University Hospital is shown below: Number of staff Number of trained eligible Completion Trust Met Name of course (YTD) staff (YTD) rate Target (Yes/No) Mental Capacity Act Level 1 70 76 92.1% 90% Yes Deprivation of Liberty Safeguards 70 76 92.1% 90% Yes

Qualified nursing staff met the trust training target for both training modules relating to the Mental Capacity Act (MCA) and Deprivation of Liberty (DoLS). Medical staff reside within the other specialties within the trust's information systems and therefore the trust was unable to provide us with medical staffing information for outpatients. However, the trust was able to provide oversight of medical staff under the specialities for each related core service.

Cromer Hospital A breakdown of compliance for Mental Capacity Act (MCA) and Deprivation of Liberty Safeguarding (DoLS) courses at September 2018 for qualified nursing staff in outpatients at Cromer Hospital is shown below: Number of staff Number of trained eligible Completion Trust Met Name of course (YTD) staff (YTD) rate Target (Yes/No) Mental Capacity Act Level 1 18 19 94.7% 90% Yes Deprivation of Liberty Safeguards 18 19 94.7% 90% Yes

Qualified nursing staff met the trust training target for both training modules relating to the Mental Capacity Act (MCA) and Deprivation of Liberty (DoLS). (Source: Routine Provider Information Request (RPIR) – Training tab) The trust had a Consent to Examination or Treatment Policy, which was available to all staff via the ‘Trust Docs’ document management system. The policy provided guidance for staff on the 20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 321 assessment of mental capacity, when consent should be sought and the information that should be given to patients, the process for documenting discussions and recording consent, and how to respond to the refusal of treatment. The policy included an appendix with sources of further information and advice. Copies of the range of consent forms were attached to the consent policy. These included a consent form for patients with mental capacity, a consent form for patients who lacked mental capacity, and a consent form for patients with mental capacity who were refusing an investigation, procedure or treatment. Departments and specialties were also encouraged to develop procedure-specific consent forms. Outpatient staff showed an understanding of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. Staff were aware of their duties and responsibilities in relation to patients who lacked mental capacity. Staff could describe what would happen where patients lacked capacity to ensure best interest decisions were made in line with legislation and guidance. We observed patient consultations in the outpatient areas we visited and observed patients giving verbal consent after comprehensive explanations of tests and examinations had been given by staff. We reviewed seven patient records and there was evidence of consent in all cases where this was relevant. We did not see any evidence of Deprivation of Liberty Safeguards in the records we reviewed during our inspection. The trust conducted audits of consent documentation in outpatient areas. The trust provided the audits for ENT in April 2018, which showed 100% compliance with trust policy. The trust audited minor oral surgery within an outpatient department in November 2018, which showed 33% compliance with trust policy. An action plan had been implemented, which included a presentation to staff at the clinical governance meeting, and re-audit was scheduled for January 2019. A mental health liaison team, provided by the local mental health, were on site 24 hours a day. All assessments for detention under the MHA were coordinated with the team from the local mental health trust.

Is the service caring? Compassionate care Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. Patients gave consistently positive feedback about the care provided by staff, who they described as kind and caring. For example, one patient told us staff were always pleasant, polite and helpful. Staff took the time to interact with patients in a respectful and considerate manner. For example, staff introduced themselves to patients, asked how they were feeling and took the time to engage in conversation. Between January 2018 and December 2018, Friends and Family Test results demonstrated an average of 95.74% of outpatients would recommend the service. Staff used curtains during patient examinations and knocked on doors before entering rooms to ensure privacy and dignity for patients. Patients could use self-check-in machines in all outpatient areas we visited, which promoted confidentiality. We saw evidence of chaperones being used in outpatient areas. The trust used chaperone stamps in patient notes to indicate where a chaperone should be in attendance as part of a consultation.

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Staff gave examples of going above and beyond for patients. For example, by staying after their shift had ended to make sure that patients had been collected by transport services and arranging for a patient’s bus fare home so they didn’t have to walk.

Emotional support Staff provided emotional support to patients to minimise their distress. Outpatient areas worked with charities and external organisations to provide emotional support to patients. For example, in ophthalmology outpatients, representatives from the local charity for blind and partially sighted people regularly attended eye clinics to provide support and advice to patients. The cardiology outpatient department worked with a national organisation offering practical and emotional support to patients with congenital heart conditions. Staff were supportive and reassuring during patient interactions. For example, we observed nursing and reception staff providing reassurance to nervous patients while in waiting areas and when they were called for their appointments. Specialist nurses and link nurses were available in outpatient areas and provided support to patients. For example, staff told us that the learning disabilities link nurses would provide support to patients with learning disabilities before and during their appointment. Specialist nurses could also refer patients to the NHS wellbeing service, a service based in Norfolk and Waveney, which provided a range of support for people with common mental health and emotional issues, such as low mood, depression or stress. The trust also had specialist nurses that were trained in cognitive behavioural therapy (CBT), which is a talking therapy used to treat anxiety and depression. The hospital had a multi-faith chapel available with prayer facilities. At least one chaplain was present within the hospital every day of the year to provide support to patients, carers and staff. Chaplains could provide support for managers in breaking bad news to other staff, offer listening and support for staff, and hold short acts of remembrance for staff members who passed away.

Understanding and involvement of patients and those close to them Staff involved patients and those close to them in decisions about their care and treatment. Patients said that staff communicated with them in a way that meant they could understand their care and treatment. We observed staff explaining the reason that tests or examinations were required. Staff were also observed explaining the outcome of tests or examinations confidentially and explaining the plan for future treatment. Patients said that they felt listened to, able to ask questions and able to contribute during consultations. For example, one patient told us staff always took the time to explain their ongoing care and they never felt rushed when in a clinic. We observed staff giving patients the opportunity to ask questions throughout their consultation and while talking to reception staff. Outpatient services arranged information evenings and open days as an opportunity to provide patients with further information and an opportunity to ask questions. For example, the cardiology outpatient service held open days for patients with congenital heart disease and information evenings were available for renal patients. Patients knew who to contact if they were worried about their condition or treatment after they left hospital.

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Staff provided people who used outpatient services with information leaflets and written information to explain their condition and treatment plan. For example, a in ophthalmology each clinic room had a range of leaflets explaining ongoing eye care and contacts for other relevant support services.

Is the service responsive? Service delivery to meet the needs of local people The trust planned and provided services in a way that met the needs of local people.

Did not attend rate From August 2017 to July 2018: • The ‘did not attend’ rate for Cromer Hospital was lower than the England average. • The ‘did not attend’ rate for Norfolk and Norwich University Hospital was lower than the England average. • The ‘did not attend’ rate for Norwich Community Hospital was generally lower than the England average, although in the most recent month (July 2018), the rate increased above the England average. • The ‘did not attend’ rate for The Roundwell Medical Centre was higher than the England average in the last four months of available data (April 2018 to July 2018).

Proportion of patients who did not attend appointment, Norfolk and Norwich University Hospitals NHS Foundation Trust.

(Source: Hospital Episode Statistics) The trust offered flexible appointments to meet the requests of local people. The trust offered telephone appointments as alternatives to face to face appointments in some areas. For example, there were nurse-led telephone clinics in haematology, oncology, diabetes, and endocrinology. Several outpatient areas offered patient advice telephone services, including cardiology and rheumatology. Cardiology had an email service to provide support and advice to patients. Ophthalmology outpatients offered a 24-hour emergency referral service with an on-call ophthalmologist. 20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 324

The trust provided some eye clinic services in the centre of Norwich and a cardiology rehabilitation programme was provided in a local village hall. Out of hours clinics continued to be held in the outpatient areas we visited in response to backlogs and demand.

Meeting people’s individual needs The service took account of patients’ individual needs. The service identified people’s individual needs through alerts on the patient record system. This included alerts for learning disabilities, patients living with dementia, and those where English was not their first language and interpretation would be required. There was a ‘Changing Places’ toilet in east outpatients. Changing Places toilets are designed for those with severe physical disabilities and are equipped with a bench and a hoist. Disabled toilets were available throughout the hospital. Wheelchairs were available at the main outpatient entrances. The main reception areas and the reception desk in the ear, nose and throat (ENT) department were fitted with an induction loop to assist people with hearing impairment. The trust arranged for deaf awareness training for all staff in areas with hearing loops to help staff understand common problems for users. Some easy read and large print leaflets were available via the document management system, staff told us these could be printed off by staff when required. The hospital subscribed to an interpreting and translation service, which provided 24-hour telephone access to trained interpreters. Face to face translation and interpretation could also be arranged when necessary. Some leaflets were available in other languages via the document management system and these could be printed off on request. The trust had two full time learning disability liaison nurses. The team received formal referrals from outpatient departments, as well as from patients and carers directly. The liaison team endeavoured to complete a person-centred care plan for each patient they assessed, which included recommendations for areas such as communication, understanding, and pain expression. Reasonable adjustments were identified and then coordinated with clinical area; adjustments could include reduced waits, quieter areas, or longer appointments. The team also provided support and training to other hospital staff about patients with learning disabilities and/or autism. Staff spoke positively about the support provided by the learning disability team. Staff could access a play therapist who attended clinics when needed to provide support for children who were frightened or had individual needs. Staff knew how to contact the palliative care team and provided positive feedback about the support provided by the team. Quality assurance audits had been carried out in some outpatient areas and some of these included questions about meeting patients’ individual needs. Questions included whether patients with physical or learning disabilities or those living with dementia were supported, whether staff could describe reasonable adjustments that would need to be made, whether patients with learning disabilities had been risk assessed and appropriate support put in place, reasonable adjustments and appropriate equipment for bariatric patients, whether communication was tailored to the individual, and staff knowledge about sourcing information in other formats and translation services.

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Access and flow People could not always access the service when they needed it. Waiting times had improved slightly since our last inspection, but waiting times from referral to treatment were still not in line with good practice.

Referral to treatment (percentage within 18 weeks) – non-admitted pathways From November 2017 to October 2018 the trust’s referral to treatment time (RTT) for non-admitted pathways has been similar to the England overall performance. The latest figures for October 2018, showed 84.8% of this group of patients were treated within 18 weeks versus the England average of 86.9%.

Referral to treatment rates (percentage within 18 weeks) for non-admitted pathways, Norfolk and Norwich University Hospitals NHS Foundation Trust.

(Source: NHS England)

Referral to treatment (percentage within 18 weeks) non-admitted performance – by specialty Nine specialties were above the England average for non-admitted pathways RTT (percentage within 18 weeks). Specialty grouping Result England average Geriatric medicine 95.8% 95.3% Rheumatology 95.7% 87.7% Ophthalmology 92.5% 89.0% Gastroenterology 92.4% 82.9% Neurology 92.2% 79.0% General surgery 91.2% 88.7% Urology 87.5% 86.5% Cardiology 86.3% 85.9% Oral surgery 84.7% 82.5%

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Eight specialties were below the England average for non-admitted pathways RTT (percentage within 18 weeks). Specialty grouping Result England average Other 90.1% 90.8% General medicine 88.8% 90.9% Gynaecology 85.0% 92.2% Thoracic medicine 83.8% 86.4% Dermatology 83.5% 89.0% Plastic surgery 78.3% 90.6% Ear, nose & throat (ENT) 73.3% 85.1% Trauma & orthopaedics 67.3% 85.9% (Source: NHS England)

Referral to treatment (percentage within 18 weeks) – incomplete pathways From November 2017 to October 2018 the trust’s referral to treatment time (RTT) for incomplete pathways has been worse than the England overall performance. The latest figures for October 2018, showed 82.6% of this group of patients were treated within 18 weeks versus the England average of 86.6%.

Referral to treatment rates (percentage within 18 weeks) for incomplete pathways, Norfolk and Norwich University Hospitals NHS Foundation Trust.

(Source: NHS England)

Referral to treatment (percentage within 18 weeks) incomplete pathways – by specialty Nine specialties were above the England average for incomplete pathways RTT (percentage within 18 weeks).

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Specialty grouping Result England average General medicine 100.0% 92.4% Geriatric medicine 98.3% 96.0% Rheumatology 96.9% 92.3% Neurology 96.3% 87.1% Gastroenterology 95.7% 89.5% Thoracic medicine 93.4% 88.4% Ophthalmology 91.5% 87.8% Dermatology 90.7% 90.3% Cardiology 90.1% 89.5%

Eight specialties were below the England average for incomplete pathways RTT (percentage within 18 weeks). Specialty grouping Result England average Other 86.8% 89.8% Ear, nose & throat (ENT) 81.1% 85.0% General surgery 80.9% 83.9% Urology 78.7% 86.1% Gynaecology 76.4% 88.6% Plastic surgery 73.2% 82.6% Oral surgery 72.9% 83.6% Trauma & orthopaedics 71.3% 81.6% (Source: NHS England)

Cancer waiting times – Percentage of people seen by a specialist within 2 weeks of an urgent GP referral (All cancers) The trust has not met the 93% operational standard in either of the most recent two quarters for people being seen within two weeks of an urgent GP referral. The performance over time is shown in the graph below. The trust’s performance has also been lower than the England average in the last two quarters. In quarter 2 2018/19, the trust’s performance was reported as 74.1%, compared to the England average of 91.6%.

Percentage of people seen by a specialist within 2 weeks of an urgent GP referral (All cancers), Norfolk and Norwich University Hospitals NHS Foundation Trust

(Source: NHS England – Cancer Waits)

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Cancer waiting times – Percentage of people waiting less than 31 days from diagnosis to first definitive treatment (All cancers) The trust is performing better than the 96% operational standard for patients waiting less than 31 days before receiving their first treatment following a diagnosis (decision to treat). The performance over time is shown in the graph below. In quarter 2 2018/19, the trust’s performance was reported as 96.6%, compared to the England average of 96.8%.

Percentage of people waiting less than 31 days from diagnosis to first definitive treatment (All cancers), Norfolk and Norwich University Hospitals NHS Foundation Trust

(Source: NHS England – Cancer Waits)

Cancer waiting times – Percentage of people waiting less than 62 days from urgent GP referral to first definitive treatment The trust has not met the 85% operational standard in any of the last four quarters for patients receiving their first treatment within 62 days of an urgent GP referral. The performance over time is shown in the graph below. In quarter 2 2018/19, the trust’s performance was reported as 72.3%, compared to the England average of 78.6%.

Percentage of people waiting less than 62 days from urgent GP referral to first definitive treatment, Norfolk and Norwich University Hospitals NHS Foundation Trust

(Source: NHS England – Cancer Waits)

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The trust provided 2018/19 quarter three data at the time of our inspection. The average percentage of people seen by a specialist within two weeks of an urgent GP referral in quarter three was 75.07%. The percentage of people waiting less than 31 days from diagnosis to first definitive treatment was 96.06%, and the percentage of people waiting less than 62 days from urgent GP referral to first definitive treatment was 71.99%. Overall, the trust had seen a marginal improvement in performance in quarter three compared to quarter two. The trust provided data on RTT from October 2018 to the end of December 2018 at the time of our inspection. The data showed that the backlog and waiting list for non-admitted patients in trauma and orthopaedics and ENT had improved over the period. Non-admitted performance had improved to 89.5% in ENT. The trust had a Referral to Treatment Access Policy, which included an 18 weeks RTT capacity and demand escalation plan. The policy set out actions that should be taken when there was an inability to book all new and follow-up appointments within allotted waiting times and required timescales. Actions included contact with clinicians to secure authorisation for overbooks and additional clinic sessions. As of 22 January 2019, there were 21 patients on a cancer pathway that had been waiting for over 100 days, and 67 patients that had been waiting between 63 and 99 days. This performance was worse than our previous inspection. The specialism where the most breaches were occurring was urology. Senior staff told us the number of patients being referred into the trust had continued to increase, but capacity and staffing had not been increased to meet demand. The trust undertook clinical harm reviews for patients and the trust Patient Tracker List (PTL) was reviewed and discussed at weekly PTL meetings to escalate those patients requiring the most urgent treatment. During our previous inspections we found that clinics frequently ran behind time. These concerns continued during this inspection. We requested data on waiting times and clinic delays, but this was not available as this was not monitored by the trust. At the time of the inspection the trust stated it was their intention that as part of ‘Perfect Ward’ there would be snap shot audits conducted on a monthly basis which will capture this data. Patients said that they expected their appointments to be late when they attended the hospital for an outpatient appointment. The trust had boards and signs in outpatient waiting areas with details of any clinic delays that day and expected waiting times. We requested data regarding the number of outpatient clinics that did not start on time and the number of clinics that over ran. However, the trust did not record or audit this at the time of our inspection. They stated that the intended monthly snap shot audits would capture this data in future. RTT training was available to all staff who managed or facilitated any part of a patient’s 18-week pathway, to ensure accurate and timely data collection. The trust used a number of dashboards to specifically monitor performance against waiting times standards. A patient tracking list (PTL), of patients who needed to be seen by given dates, in order to start treatment within maximum waiting times, was produced on an at least twice weekly basis. The trust PTL also showed when patients were approaching a pathway milestone without a date for that pathway event. The PTL was reviewed and discussed at weekly PTL meetings. The trust had also developed a referral to treatment time dashboard to monitor weekly performance against targets and progress against the recovery trajectory. The dashboard included RTT remedial action plans for 15 specialties. The trust had also developed an outpatient appointments summary which showed current waiting times, including by priority. This could be filtered by specialty, referral source, receipt method and appointment type.

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In the six months prior to our inspection, 9,848 clinics had been cancelled (this excludes rescheduled clinics), and 1,848 (18.8%) of these were cancelled within six weeks of the clinic. The trust’s referral to treatment access policy stated that six weeks’ notice must be given for clinic cancellations and the chief of division and divisional managers must give authorisation for cancellations under six weeks. The trust provided a number of rapid access or ‘hot’ clinics, which are same day or next day appointments that are made available to patients requiring acute clinical input quickly. The service arranged 11 physiotherapy rapid access clinics primarily to support trauma and orthopaedics patients. The speech and language therapy (SALT) team arrange daily valve change clinics every lunch time for patients with speaking valves. The patient can call ahead and the team see the patient the same day to have the valve changed. Cardiology had a nurse led rapid access chest pain clinic and a registrar led clinic that ran three times a week. Cardiology also had cardiac rehabilitation clinics where patients get to see a specialist nurse, physiotherapist, occupational therapist, and dietician, all in a one stop visit to avoid unnecessary repeated visits. Outpatients diabetes service offered a drop-in clinic Monday to Friday 9am to 10am. Patients diabetes annual reviews are also treated as one stop clinics with full bloods and screening observations, eye check-up, foot check, with a diabetes specialist nurse and a dietician available. In ophthalmic outpatients department, they offered an ophthalmic emergency referral service which was a hot clinic.

Learning from complaints and concerns The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.

Summary of complaints From October 2017 to October 2018 there were 186 complaints about outpatients. The trust took an average of 32 days to investigate and close complaints, and 34.4% of the complaints were closed within 25 days. This is not in line with their complaints policy, which states that more than 50% of complaints should be closed within 25 days. A breakdown of complaints by site and subject can be found below.

Norfolk and Norfolk University Hospital Number of Percentage of Core service complaints total complaints Appointments including delays and cancellations 41 23.3% Communications 41 23.3% Clinical Treatment - Surgical 39 22.2% Clinical Treatment - General Medical 15 8.5% Waiting Times 10 5.7% Values and Behaviours (Staff) 8 4.5% Trust Administration 5 2.8% Clinical Treatment - Radiology 3 1.7% Access to Treatment or Drugs 3 1.7% Privacy, Dignity and Wellbeing 2 1.1%

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Other 2 1.1% Consent 2 1.1% Facilities 1 0.6% Patient Care including Nutrition/Hydration 1 0.6% Clinical Treatment - Anaesthetics 1 0.6% Clinical Treatment - Dental 1 0.6% Admission, Discharge and Transfers 1 0.6% Total 176 100.0%

Cromer Hospital Number of Percentage of Core service complaints total complaints Appointments including delays and cancellations 4 40.0% Trust Administration 1 10.0% Other 1 10.0% Clinical Treatment - Surgical 1 10.0% Values and Behaviours (Staff) 1 10.0% Commissioning Services 1 10.0% Communications 1 10.0% Total 10 100.0% (Source: Routine Provider Information Request (RPIR) – Complaints tab)

Number of compliments made to the trust From October 2017 to September 2018 there were 59 compliments within outpatients. A breakdown by site and ward can be found below.

Norfolk and Norwich University Hospital Percentage of Number of Ward name/area total compliments compliments Urology Outpatients 8 14.8% Ophthalmology Outpatients 8 14.8% General Surgery Outpatients 7 13.0% Cardiology Outpatients 6 11.1% ENT Outpatients 5 9.3% Respiratory Outpatients 3 5.6% Trauma and Orthopaedic Outpatients 3 5.6% Fracture Clinic 3 5.6% Oral Health OMFS Outpatients 3 5.6% Outpatient Booking Service 2 3.7% Plastic Surgery Outpatients 2 3.7% Endocrinology Outpatients 2 3.7% Older People's Medicine Outpatients 1 1.9% Rheumatology Outpatients 1 1.9% Total 54 100.0%

Cromer Hospital

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Percentage of Number of Ward name/area total compliments compliments Cromer Outpatients 5 100.0% Total 5 100.0% (Source: Routine Provider Information Request (RPIR) – Compliments tab) The trust’s Complaints Policy and Handling Guidelines were available to all staff via the trust document management system. The policy set out the process for investigating, responding and learning from complaints. The majority of staff we spoke to were aware of the complaints procedure and said that they would attempt to resolve complaints informally in the first instance. PALS leaflets were available in the areas we visited and staff said that they gave these to patients and carers who raised a concern or complaint. None of the patients or relatives spoken to on inspection had made a complaint. The majority were not aware of the process by which to make a complaint, but said they would ask a member of reception or nursing staff if they wanted to raise a complaint. The trust had a hospital satisfaction survey specifically for patients with learning disability and/or autism, which asked what was good, what was not so good, and how the hospital could make things better. Easy read leaflets were also available on how to make a complaint and for the patient advice and liaison service (PALS). Staff were able to provide examples of changes that had been made as a result of complaints, as well as concerns raised through friends and family test (FFT) feedback. This showed that complaints and concerns were used as an opportunity to learn and drive improvement. For example, in ophthalmology, staff had introduced the information board with details of any delays and waiting times for each clinic. Staff were aware of the themes in complaints received in their areas, which most staff identified as parking and waiting times. Meeting minutes showed that complaints were discussed at clinical governance and team meetings.

Is the service well-led? Leadership Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care. The trust was divided into four divisions; Medicine, Surgery, Women and Children’s Services, and Clinical Support. There was a chief of division, divisional operations director, and divisional nursing/clinical services director for each division. The chiefs of division reported to the chief operating officer and were part of the management board with the executive directors. Each Outpatient speciality sat within the relevant divisions. There was no overall lead for outpatient services. All outpatient managers took active part in the outpatient forum and transformation project. Staff described divisional leaders and matrons as visible and approachable, and stated that they saw members of the executive team on occasion. Staff said that they had the opportunity to meet and engage with members of the executive team through regular staff forums. Staff understood

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 333 the leadership structure for their area and knew who their line manager was. Staff said that their managers were approachable and supportive. Managers of individual outpatient areas were experienced and capable of leading their teams. Managers in all the areas we visited had received leadership development training. Managers had an understanding of the challenges to quality and sustainability in their areas, for example regarding actions to reduce patient waiting times. Quality assurance audits had been carried out in some outpatient areas and these included questions about the visibility of the executive members and whether staff could name key managers and board members appropriate to their role. However, the leadership section in the audits the trust provided at the time of the inspection had not been completed in most audits. The section had been completed in the phlebotomy audits, which did evidence good staff knowledge of the trust leadership team.

Vision and strategy There was no specific long-term vision or strategy for the outpatient services as a whole. However, staff understood the challenges facing their specific area and knew of the plans to improve trust performance in their speciality. The trust vision was ‘to provide every patient with the care we want for those we love the most’. The trust values were PRIDE: people-focused, respect, integrity, dedication, excellence. All staff we spoke with were aware of the acronym ‘PRIDE’, and most knew the individual values that the acronym stood for. Staff spoke positively about an increase in focus on the trust values, with team meetings, forums and The trust’s strategy had four objectives: 1) We will be a provider of high quality health and care services to our local population; 2) We will be the centre for complex and specialist medicine for Norfolk and the Anglia region; 3) We will be a centre of excellence for research, education and innovation; 4) We will be a leader in redesign and delivery of health and social care services in Norfolk. Staff told us that quality assurance audits had been carried out in some outpatient areas, which included questions about whether staff knew the quality strategy, whether they could articulate their contribution towards achieving the strategy’s aims and priorities, if staff knew how well the organisation was performing regarding the trust’s quality priorities, and whether staff knew what their local quality priorities and areas for improvement were. From the audits provided by the trust phlebotomy staff had been asked about strategy. The audit in the phlebotomy service included positive results from the workforce on knowledge of the quality strategy for that particular service.

Culture Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. There was a positive culture in outpatient areas. Staff said that they felt supported, respected and valued. Staff described cooperative, supportive and appreciative relationships with colleagues. The culture was centred on the needs and experience of people who used the services.

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Staff said that they felt positive and proud to work in the organisation. Many staff members had been working for the trust for a significant number of years. Staff described working in a friendly and welcoming team. Staff said that they felt able to raise concerns when necessary. Minutes from the outpatient forum meetings showed that a wide range of staff were engaged in improving the perception and visibility of outpatient services throughout the trust and local community and staff spoke positively about the increased focus on outpatient areas through the introduction of the forum and transformation project. Outpatient staff had been represented on the ‘staff experience working group’, which was established to improve culture and morale throughout the trust. Quality assurance audits had been carried out in some outpatient areas and some of these included questions about culture. Questions asked whether staff ever felt bullied, whether staff felt they would be blamed or disadvantaged if they reported an incident or concern, if staff felt well supported when involved in an incident or complaint, whether staff felt treated fairly by managers (regardless of their background), and whether patients were at the heart of everything staff did. Staff feedback in audits confirmed staff felt supported and that the trust had a positive culture.

Governance The trust used a systematic approach to improve the quality of its services and safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish. However, concerns raised at our previous inspections had not been resolved at the time of this inspection. Clinical governance meetings were held within each specialty, combining both inpatient and outpatient services. We saw evidence in meeting minutes that matters relating to outpatient areas were discussed in these meetings, with the majority of meetings being held on a monthly basis. Staff said that governance related information was fed down to them through regular team meetings and team briefs from senior nurses. This was confirmed through minutes from team meetings in some outpatient areas. Quality assurance audits included questions about whether staff understood the governance reporting framework and how issues were reported upwards, as well as fed back downwards. There was a governance process in place for the management of waiting lists and treatment time performance. Cancer assurance, referral to treatment and diagnostics meetings fed into the trust access group, which involved deputy operational directors. This fed into a monthly access standards group, which had representation from clinical commissioning groups (CCGs), divisional directors and the chief operating officer. Staff were clear about their roles and understood what they were accountable for, and to whom. Some quality assurance audits included a question about whether individuals were clear about their responsibilities, but it was not clear what action had been taken to improve governance as a result of audits. We found issues that had been raised at our previous inspections, including temperature recording of medicine rooms and security of patient records that had not been resolved at the time of this inspection and the trust did not provide evidence of its ongoing governance of the concerns.

Management of risk, issues and performance

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The trust had systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. However, they were not always effectively implemented. The outpatient risk register was divided across each divisional risk register. The outpatient risk register contained 25 risks, eight of which had been on the risk register for over three years. However, this was an improvement on our previous inspection. Whilst there was evidence of ongoing monitoring and review of these risks, the length of time that the risks had been on the register indicated that risks were still not being resolved in a timely manner. The risk register showed a high risk in ophthalmology outpatients that had been on the register since 2013, regarding delays in patient follow-up appointments. The trust had taken a number of actions to mitigate the risk, including patients being diverted to alternative pathways appropriate to their condition, consultant leave being backfilled to avoid cancelling clinics, and extra clinics run on an ad-hoc basis when possible, in an attempt to reduce the backlog of follow ups. However, the trust had two serious incidents in the last 12 months where patients eye sight had deteriorated while waiting for a delayed follow up appointment. The risk was last reviewed in January 2019 where it was stated the trust was working through a high impact intervention plan to reduce the backlog, which was improving performance. However, the risk score remained the same, because the risk to patients in the backlog remained. The oldest risk on the register was from February 2012, which was regarding the space allocated to the orthotics department being insufficient to deliver the service safely and in accordance with fire regulations, as identified in a fire risk assessment in August 2011. However, the trust had taken several actions to mitigate the risk, including increasing storage space and reducing the amount of equipment being stored in the clinic. The risk was last reviewed in September 2018 and remained medium. The trust had a long-term plan to increase the amount of space for the department to bring it in line with required standards. Risks identified on our last inspection regarding medicine and records storage had not been resolved and did not appear on the risk register. Scrutiny of the risk register took place at clinical governance meetings for each specialty and at divisional level. The trust had launched a new outpatient dashboard. The dashboard had productivity and performance indicators for all specialities including clinic utilisation, did not attend rates, templated annual leave, and follow up ratios. Staff told us the dashboard would primarily be used by operational managers to track performance and report to senior management. Integrated performance reports were produced on a monthly basis for each division to manage risk, issues and performance. Reports included an update on progress against the five-year strategy, data on performance against treatment times and waiting lists, activity levels, a review of risks and action logs, a workforce summary, and a review of financial performance. The reports also included a review of quality and safety through a review of incidents, complaints, and infection control. Outpatient areas were monitored as part of these reports; there was no separate performance report for outpatients. A trust wide integrated performance report was also in use during trust board meetings and these included a review of cancer performance and referral to treatment times.

Information management

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The service did not always manage information effectively. Staffing related information held by the trust did not always clearly show outpatient staff, especially for medical staff. Staff had access to policies, standard operating procedures and patient information leaflets electronically through the document pages on the trust intranet. Staff confirmed that this ensured that information was easily accessible and up to date. The divisional integrated performance dashboards showed a holistic understanding of performance, which sufficiently covered and integrated people’s views with information on quality, operations and finances. Information was used to measure for improvement by comparing performance with the previous year and displaying the six-month trend in performance. The trust had implemented a new outpatient specific dashboard that was launched at the time of our inspection, which included all outpatient specialities covering performance and productivity. Staffing related information, such as training, appraisals and vacancy numbers, held by the trust did not always clearly show outpatient staff, especially for medical staff. This could produce challenges for the trust to separately monitor outpatient performance in these areas and identify any issues specifically related to medical staffing in outpatients.

Engagement The trust engaged with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively. Staff told us they were encouraged to attend the outpatient forum to share learning, best practice and ideas for the future. The outpatient forum had also led on workshops in October 2018 for staff to input on the current outpatient experience and how the ideal future outpatient experience would look and feel. Members of staff that were active participants in the outpatient forum had also attended and NHSI outpatient improvement event in November 2018 to learn from best practice and plan the trust approach to transformation. Staff said that they felt engaged through regular team meetings, where they were encouraged to provide feedback. Staff said that the senior leadership team held open forums on a regular basis, such as the bi-monthly viewpoint sessions with the chief executive, and sent out regular email updates. The quality assurance audits that had been carried out in some outpatient areas included questions about whether staff believed that their views and feedback were sought and valued to help shape services for patients and for staff. The outpatient services did not currently pro-actively engage with the general public. Public governors attended the outpatient forum to provide a viewpoint from the patients and relatives perspective. Part of the outpatient services transformation programme plan for 2019 was to create an outpatient patient forum where past and present patients, relatives and carers could come together to share their experiences and feedback to the trust on positive experiences and suggested areas of improvement for the trust. People’s views and experiences were gathered and acted on to shape and improve the services and culture through the trust wide patient surveys that were carried out in some outpatient areas. The trust provided evidence of changes through patient feedback on ‘you said, we did’ boards in patient waiting areas. Quality assurance audits (QAA) were carried out in some outpatient areas. QAAs were unannounced clinic inspections carried out by a team of two senior nurses and an independent external representative from local voluntary and community groups. The QAA team inspected

20190325 Norfolk and Norwich University Hospitals NHS Foundation Trust 337 standards of care provided to patients, and the community representative was primarily responsible for talking with patients and families to listen to their feedback.

Learning, continuous improvement and innovation The trust was committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation. The trust had launched an “Outpatient Services Transformation” programme, based on the principles of “Leading Large-Scale Change” in October 2018. The programme had overseen the implementation of the new outpatient dashboard and the implementation of conduct standards across outpatient areas. The programme included plans for the future, including standardisation of letter templates, improved clinic room utilisation, and virtual appointments. The trust offered patients requiring home ventilation a dedicated troubleshoot clinic with ad-hoc appointments. The speech and language therapy team were taking part in a two year study to evaluate the effectiveness and cost-effectiveness of two types of speech and language therapy for people with Parkinson’s disease who have self-reported problems with voice or speech.

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