Bradford Teaching Hospitals NHS Foundation Trust

Evidence appendix Trust Headquarters Date of inspection visit: Bradford Royal Infirmary 9 to 11 January 2018 and 6 to 8 Bradford February 2018 West Yorkshire BD9 6RJ Date of publication: xxxx> 2018 Tel: 01274 542200 www.bradfordhospitals.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 Details of sites and locations registered with CQC

A list of the acute and community hospitals at the trust is below:

Details of any Name of acute Geographical area Address specialist services hospital site served provided at the site Children Community Nurse Team Bradford Royal Duckworth Ln, Bradford Medical Care Bradford Infirmary BD9 6RJ Outpatients Surgery Eccleshill 450 Harrogate Road, Community Eccleshill , Bradford, West Outpatients Eccleshill Hospital Yorkshire, BD10 0JE

98 Kirkgate, Shipley, West Shipley Hospital Outpatients Shipley Yorkshire. BD18 3LT

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Children Community Nurse Team St Luke's St Luke's Hospital, BD5 Medical Care Bradford Hospital 0NA Outpatients Surgery

Westbourne 26 Heaton Road, Bradford, Medical care Westbourne Green West Yorkshire BD8 8RA Outpatients

Westwood Park Diagnostic and Swift Drive, off Cooper Medical care Westwood Park Treatment Lane. BD6 3NL Outpatients Centre (Source: Trust Website)

Bradford Teaching Hospitals NHS Foundation Trust provides acute clinical services from the above locations. We inspected at Bradford Royal Infirmary which is the larger of two main hospital sites providing acute clinical services for. The hospital is based in Bradford and provides all clinical services from urgent and emergency care to maternity and services for children and young people.

The trust has over 800 beds including 60 maternity beds and 22 critical care beds at Bradford Royal Infirmary. The trust saw over 93,500 inpatient admissions between December 2016 and November 2017. There were also over 519,000 outpatient attendances in the same period. There were over 123,000 A&E attendances.

The trust was inspected in October 2014 and January 2016. At the comprehensive inspection in October 2014 we found the trust was in breach of regulations relating to care and welfare of people, assessing and monitoring the quality of the service, cleanliness and infection control, safety, availability and suitability of equipment and premises, respecting and involving service users and staffing. We issued a number of notices which required the trust to develop an action plan for how they would comply with the regulations where breaches had been found.

We reviewed the trust’s progress against the action plan during the follow-up inspection in January 2016. We found that there had been improvements in some of the services and this had resulted in a positive change in the overall ratings from the previous CQC inspection, notably in critical care and outpatients and diagnostic imaging. However, the ratings remained the same in accident and emergency, surgery, medicine and children’s and young people’s services. This was because we either did not see significant improvement from our previous inspection or because we identified new areas of concern.

The trust has a financial turnover of £393,573,000 and had a £11m deficit for 2017/18. NHS improvement (NHSi) reported that the trust had a good track record of ensuring delivery of overall financial plans. The trust achieved the financial plan and exceeded the control total in 2016/17. The trust also achieved its cost improvement programme (CIP) plan on a recurrent basis in 2016/17.

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 above the England average for recommending the trust as a place to receive care from Dec 2016 to August 2017 but scored similar to the England average from September 2017 to November 2017. However, the trust response rate was 14.8% against a 22.7% England average.

Is this organisation well-led?

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Leadership

The trust board consisted of:  The Chair (appointed in November 2016)  Chief Executive Officer (appointed in January 2015)  Director of Governance and Corporate Affairs / Deputy Chief Executive (appointed in February 2015)  Medical Director (appointed in May 2015)  Chief Nurse (appointed in August 2016)  Director of Human Resources (appointed in December 2008)  Director of Finance (appointed in August 2012)  Chief Operating Officer (appointed in February 2018)  Director of Informatics (appointed in September 2013)  Director of strategy and Integration (appointed in August 2016)  Eight Non-executive Directors

The trust board had the appropriate range of skills, knowledge and experience to perform its role. The board of directors’ portfolios covered all key areas. The current chair, chief nurse and director of strategy and integration had been appointed since our last inspection in 2016. The chief operating officer (COO) was appointed in February 2018 having been in an interim COO role since January 2018. The director of governance and corporate affairs planned to retire at the end of March 2018. The assistant director of governance and risk had been identified to take this role from April 2018.

The trust had appointed three non-executive directors since our last inspection in 2016. This included two non-executives that joined in December 2017 and February 2018. The non- executives were knowledgeable, competent and had the appropriate skills and experience relevant to their roles. They had worked in leadership and management positions in the NHS, education, voluntary and private sectors. They had a background in a range of areas including business planning, law and accountancy. The non-executive team provided appropriate challenge and were positive about trust leadership. They demonstrated a clear understanding that cost improvements and financial performance should not compromise patient care and safety.

The chair, executive and non-executive directors demonstrated a clear understanding of the priorities and challenges facing the trust. Senior leaders spoke with insight about key risks around workforce, maintaining operational performance and financial pressures. These challenges were articulated in the clinical service strategy and were recognised in the corporate risk register and Board Assurance Framework.

We carried out checks to determine whether appropriate steps had been taken to complete employment checks for executive and non-executive directors in line with the Fit and Proper Persons Requirement (FPPR) (Regulation 5 of the Health and Social Care Act (Regulated Activities) Regulations 2014). This regulation ensures that directors of NHS providers are fit and proper to carry out this important role. We looked at the executive and non-executive director employment files, which were completed in line with the FPPR regulations.

The council of governors approved the appraisal process for the chair and non-executive directors. Performance appraisals for non-executive directors went to the nominations and remuneration committee. Newly appointed executive and non-executive directors underwent formal induction, which included mandatory training and a local induction plan specific to their role.

Most staff reported that the leadership team were visible and approachable. The executive and non-executive directors undertook a scheduled programme of walkabouts across the directorates

20171116 900885 Post-inspection Evidence appendix template v3 Page 3 and reported these back at board meetings. The chief executive also engaged with staff through regular informal talks.

There were processes in place for leadership development and succession planning across the senior and divisional management levels. The leadership strategy 2017– 2022 set out how the trust aimed to meet the leadership strategic aims and objectives in the people strategy 2017 – 22. A leadership and management development framework was launched in 2017. This outlined the plan to deliver training and development to staff in leadership roles across the trust, including senior leaders. Potential or future leaders were identified through appraisals, career development conversations and/or informally, through recognising skills and capability.

Of the executive board members at the trust, none were black and minority ethnic (BAME) and 50.0% were female. Of the non-executive board members 38.0% were BAME and 25.0% were female. This was not fully representative of the local demographics.

Staff group BME % Female %

Executive directors 0.0% 50.0%

Non-executive directors 38.0% 25.0%

All board members 19.0% 38.0%

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

Vision and strategy The trust published its refreshed mission and vision statements along with its strategic objectives in August 2017. The trust’s mission was "To provide the highest quality healthcare at all times”. The trust's vision was "To be an outstanding provider of healthcare, research and education, and a great place to work". The vision was underpinned by the following four values;  we care,  we value people,  we strive for excellence  we make every penny count

The trust had the following five strategic objectives: -  To provide outstanding care for patients  To deliver our financial plan and key performance targets  To be in the top 20% of NHS Employers  To be a continually learning organisation  To work effectively with local and regional partners

The overall responsibility for the delivery of each strategic objective was assigned to a named executive director. The strategic objectives were aligned with the ambitions set out in the clinical service strategy 2017 – 2022. The clinical service strategy had been developed in line with the NHS Five Year Forward View and the West Yorkshire and Harrogate Sustainability and Transformation Plan (STP). The clinical service strategy described how the trust planned to meet the changing needs of the community it served. The strategy had four themes: -

 High quality care  Research-led care and learning  Collaborative hospital care

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 Connected local care

A wide range of staff had been involved in the development of the mission, vision and values statements and the clinical service strategy. There had been approximately 40 engagement meetings held with staff at all levels in clinical specialties across the trust between December 2016 and March 2017. The views of executive and non-executive directors, governors and other senior managers from across the trust had also obtained through a range of different meetings and forums.

The clinical service strategy was supported by a number of other core strategic plans, strategies and framework documents. These included the financial plan 2017/18 and people strategy 2017 - 2022. The quality plan 2018-2019 supported the trust’s clinical service strategy and outlined a number of goals and targets that were aligned with the Care Quality Commission’s regulatory framework.

The people strategy 2017 – 22 was published in April 2017. This outlined the trust’s commitment to developing a modern workforce, with the skills, flexibilities, values and behaviours to deliver new models of healthcare and support the delivery of overall trust priorities. There were five strategic aims outlined in the strategy; attract, develop, retain, happy, healthy and here and to lead. These included objectives around recruitment, engagement, staff development and equality and diversity. Progress against objectives was monitored through the workforce committee, which met every two months and was chaired by a non-executive director.

The nursing, midwifery and AHP framework was developed and launched on the 21 November 2016. The estates plan and strategy was due for renewal in December 2018, but was planned to be updated with a draft in place by August 2018 to reflect the updated clinical service strategy.

The research strategy 2016 - 2021 was in place and was aligned with the research objectives in the clinical service strategy. The education strategy was in the process of being updated so that it was aligned with the clinical service strategy. The director of education planned to use this as an opportunity to engage the whole education team and undertake a consultation process. A draft education strategy was planned for the end of March 2018.

The trust had a Clinical Informatics strategy 2014-19, IT strategy 2015-19 and Intelligent Use of Information strategy 2015-19. The executive team approved a decision in January 2018 to develop a new overarching Clinical Informatics Strategy. A draft strategy was planned to be in place by May 2018.

The vision and values were shared with staff across the trust via the “Let’s Talk” magazine, posters and screensaver slides used on the trust network. Most staff we spoke with understood the trust’s vision and values. The executive and non-executive directors shared the trust’s vision and values and were committed to implementing the clinical service strategy.

Sustainability and transformation plans (STP) are part of a national programme where the NHS, local authorities and social care form partnerships to improve health, the quality of social care and efficiency of services in a geographical ‘footprint’. The STP processes will inform part of the overall long-term strategy for the trust in terms of service configuration. Bradford Teaching Hospitals NHS Foundation Trust was part of the West Yorkshire and Harrogate STP. The trust did not have its own separate STP future implementation plan but provided input and representation into the STP’s formal programmes of work, as well as its corporate and strategic decision making governance.

Senior staff were involved in various areas of the STP work. The CEO was a member of the system leadership executive group (SLEG). This group was responsible for setting and overseeing the strategic direction, building leadership and collective responsibility for the STP’s shared objectives, including oversight of financial decision making such as the move towards the

20171116 900885 Post-inspection Evidence appendix template v3 Page 5 agreement of a single control total for the STP. The SLEG was also advised by an STP finance directors group, which included the trust’s finance director.

The trust contributed to the ongoing and future operational work of the STP through the West Yorkshire Association of Acute Trusts (WYAAT). This is a Committee in Common (CiC) of all the acute trusts in West Yorkshire with an underpinning memorandum of understanding (MoU) and is the vehicle through which the STP delivers its planned acute collaboration programme. The Chair and CEO were members of the CiC. There were also a number of on-going WYATT programmes and work streams and senior staff were involved in each of these.

The trust was in the process of developing an overarching mental health strategy. The draft strategy was assured by the clinical audit and effectiveness board sub-committee and due to be published in early 2018. The main objectives identified in the strategy were to provide mental healthcare services, to support and train staff to be able to feel confident in helping patients with mental health conditions and to integrate mental healthcare and physical healthcare. The strategy was developed following the publication of the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report Mental Health in General Hospitals: Treat as one (2017) report.

The chief nurse was the executive lead for mental health across the trust. The chief nurse reported that the trust did not routinely audit the outcomes of mental health patients in order to identify opportunities to improve care. A mental health working group was set up to oversee the development of the strategy and implementation of the development NCEPOD guidance. The role of the group included completion of the self-assessment checklist, implementation of audits using the NCEPOD audit tool every three months and to provide training and raise awareness among staff.

Staff in the emergency department and ward areas were able to seek advice about mental capacity, Deprivation of Liberty Safeguards and other issues related to mental health from the safeguarding team, the onsite psychiatric liaison and first response teams provided by the local mental health trust during out of hours. There were good working relationships with the liaison team. Staff told us they received a timely response to referrals to the service and could also ring and ask for advice and information at any time.

The chief pharmacist had a broad awareness of the challenges to the quality and sustainability of the pharmacy service. The pharmacy strategy was based on the Hospital Pharmacy Transformation Plan. This was supported by a vision and objectives document which had been reviewed in 2017. The chief pharmacist had a vision to prioritise patient facing clinical care, and a number of pilots and projects were planned to provide data to drive forward improvements. Culture There was a positive culture across the trust with a strong focus on patient safety. The trust’s vision and values were cascaded across the trust and staff demonstrated the values of the organisation. Most staff felt appreciated and proud about working for the trust and within their teams. There was effective multidisciplinary working and teamwork.

Staff we spoke with described an open, inclusive and honest culture. They felt they received good support and were encouraged to develop their skills to enable the delivery of safe care and treatment to patients. Medical staff reported a good level of clinical input with the ability to improve services. Staff told us they felt able and confident to discuss issues or concerns with their leaders. The chief executive and board members were described as being visible, open and approachable and most staff were confident they could raise concerns and would be listened to.

The board members, senior management team and divisional management teams worked well together. The non-executive directors and council of governors demonstrated a culture of constructive challenge and mutual respect.

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The guardian of safe working hours was appointed in December 2016. This role was introduced nationally to protect patients and doctors by making sure doctors were not working unsafe hours. The guardian oversaw exception reporting and highlighted any identified concerns or trends in relation to junior doctor’s working hours, rotas, and breaks or missed training. The guardian worked with the education supervisor to identify actions, explore any immediate solutions and implement remedies.

The guardian of safe working hours reported to the medical director, the education and workforce subcommittee and to the trust board every three months. There was a junior doctor’s forum, where representatives from all specialities at a variety of grades attend to discuss and share ideas for improvement and provide opportunities to enhance skills. The program of associate college tutors also reviewed rotas and sent representatives to the junior doctor’s forum.

Junior doctors spoke positively about working for the trust. They told us they received good support and that registrars and consultants were available when needed. Most junior doctors felt their workload was balanced. However, junior doctors in the general medicine specialty felt they did not always get the time to complete their training and development because of their on-call rota commitments.

The guardian of safe working hours report for the period September 2017 to December 2017 highlighted that junior doctor in the obstetrics and gynaecology specialty frequently working beyond contracted hours. Actions to improve this were developed within the department.

The chief nurse was appointed as the Freedom to Speak up Guardian in 2016. The Freedom to Speak up Guardian was supported by a team of 10 trained Associate Guardians that were appointed from different areas across the trust. The chief nurse told us the use of the Associate Guardians across different areas of the trust allowed them to be independent and impartial when reviewing cases.

The Freedom to Speak up process was launched during April 2017 and was communicated through engagement, newsletters and promotional materials. Training in freedom to speak up had been included in the induction process for new staff. There were 25 cases reported between June 2017 and February 2018. These had been investigated appropriately and learning was shared with the individual that raised the concern as well as across the trust. A progress report was submitted to the quality committee and trust board every three months. The chief nurse also discussed reported cases with the chief executive on a monthly basis.

The trust had been compliant with the statutory and contractual Duty of Candour requirements for all incidents reported during 2017. Duty of Candour states the trust must act in an open and transparent way about the care and treatment patients receive and notify them, as soon as is reasonably practicable, after becoming aware that a notifiable safety incident has occurred, firstly in person and then in writing.

The trust had a Duty of Candour policy that was implemented in July 2017. This was supported by an awareness campaign including a ‘Learning Matters’ newsletter publication and the development of an intranet site. Compliance was monitored by the risk management administration team. The risk management team also provided support to staff where required.

Staff Diversity The trust provided the following breakdowns of medical and dental and nursing and midwifery staff by ethnic group:

Medical and dental Nursing and Ethnic group staff (%) midwifery staff (%) White 58.73 70.82

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Mixed 1.01 1.43 Asian 26.55 10.62 Black 2.74 3.26 Chinese 1.73 0.23 Other 1.73 11.31 Unknown / Not Stated 7.22 2.34

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

The trust did not have a standalone equality and diversity strategy. Equality and diversity was incorporated into the people strategy 2017 – 22. The trust launched the equality objectives 2016 – 2020 in April 2016. These were developed following involvement with the local voluntary and community sector, staff and public sector partners and an external consultation process which had 156 individual responses. The objectives set out the eight equality priorities for the trust to focus on. The priorities included the implementation of NHS Accessible Information Standard, Workforce Disability Equality Standard and the Workforce Race Equality Standard along with a focus on key areas such as gender pay gap and mental health awareness. Progress against the equality objectives was monitored every six months by the trust board.

There was a head of equality and diversity in place along with staff network groups for black, asian and minority ethnic (BAME) staff, disabled staff and lesbian, gay, bisexual and transgender (LGBT) staff. Equality impact assessments were carried out against core business policies, improvement projects, reports and risk assessments. These identified if there was likely to be any impact on any of the protected characteristics (such as age, gender, race and sexual orientation) and to mitigate the likely impact.

The trust participated in the pilot Workforce Disability Equality Standard (WDES) in November 2017 conducted by NHS England. The head of equality and diversity was working with the disabled staff network to identify action needed to improve the working lives of disabled staff. The trust organised two events in January 2018 to meet with disabled staff, talk through the findings from the WDES pilot and agree actions to take forward.

The trust commissioned a whole nurse and midwifery staff survey that took place during February and March 2017. The survey results showed a mixed response about the experiences of BAME and disabled staff. Following the survey, the head of equality and diversity was tasked to set up a task and finish group to look at the findings and make recommendations for improvement. The task and finish group comprised of staff from the BAME and disabled staff networks, matrons and staff from human resources (HR). Recommendations from the group would report through the Diversity work stream group that held meetings every two months. The work stream was chaired by a director and attended by the head of equality and diversity.

Workforce race equality standard The scores presented below are the un-weighted question level score for question Q17b and un- weighted scores for Key Findings 25, 26, and 21, split between White and Black and Minority Ethnic (BME) staff, as required for the Workforce Race Equality Standard.

Note that for question 17b, the percentage featured is that of “Yes” responses to the question. Key Finding and question numbers have changed since 2014.

In order to preserve the anonymity of individual staff, a score is replaced with a dash if the staff group in question contributed fewer than 11 responses to that score.

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Of the four questions above, one question showed a statistically significant difference in score between White and BME staff:

 Q17b: In the 12 last months have you personally experienced discrimination at work from manager/team leader or other colleagues?

(Source: NHS Staff Survey 2016)

The trust board set a target of 35% of staff from BAME groups to reflect the local population by 2025. Progress against this target was monitored every six months by the board. An equality report submitted to the January 2018 board meeting (April to September 2017 data) showed the trust had a higher proportion of BAME staff at Bands 1-7 but a lower percentage at Bands 8 and above when compared to national results and other acute trusts. On the current trajectory the trust was on target to exceed the 35% recruitment target for BAME staff at Bands 1-7 by 2025. There had been an increase of 1.78% in the overall percentage of BAME staff in Bands 8 and above posts compared to April 2018. However, on the current trajectory the trust would fall short by around 14% to have a BAME senior management workforce of 35% by 2025 (assuming a similar percentage increase every six months).

The equality report also showed the trust performed average or better than average in comparison to national results and other acute trusts on a number of indicators, including BAME staff being appointed from shortlisting, entering formal disciplinary process, accessing non-mandatory training and development, harassment, bullying or abuse from the public and believing that the trust provided equal opportunities for career progression or promotion. However, the trust was below average for the proportion of BAME staff experiencing harassment, bullying or abuse from staff and discrimination from manager/team leader or other colleagues.

There was a workforce race equality standards (WRES) 2017 action plan that included a range of actions that were planned or already completed in relation to improving fairness during recruitment and promotion and in relation to improving reporting and support processes for BAME staff experiencing bullying and harassment. These actions had a named responsible individual and a target completion date.

Most staff we spoke with in focus groups and at the core service inspection did not reveal any discrimination. However, staff in the BAME and disability network representatives’ focus group echoed some of the findings from the staff survey, nurse and midwifery staff survey and equality

20171116 900885 Post-inspection Evidence appendix template v3 Page 9 report findings. They described specific examples of alleged discrimination and in difficulties obtaining reasonable adjustment for disabled members of staff.

The director of human resources reported that a review of the trust harassment and bullying Policy was started following an initial planning meeting with the BAME staff network, and will incorporate the new role of staff advocate. The review was expected to be completed by the end of March 2018.

The BAME network held meetings every two months and had approximately 60 members. Staff told us the disability network had lost its chair a year ago and there were not enough members to ensure the longevity of the group with only 14 members. They told us that representation of BAME staff was predominantly at lower levels of seniority and that there was limited development opportunities offered to these staff. There were plans to launch promotional events for all networks with the support of the diversity work stream and some funding from the board.

NHS Staff Survey 2016 – results better than average of acute trusts

The trust has one key finding that exceeded the average for similar trusts in the 2016 NHS Staff Survey:

Key Finding Trust Score National Average

Percentage of staff/colleagues reporting most recent 57% 45% experience of harassment, bullying or abuse

NHS Staff Survey 2016 – results worse than average of acute trusts

The trust has nine key findings worse than the average for similar trusts in the 2016 NHS Staff Survey:

Key Finding Trust Score National Average

Response Rate % 39% 43%

Support from immediate managers. 3.66 3.73

Percentage of staff reporting errors, near misses or 87% 90% incidents witnessed in the last month.

Effective use of patient / service user feedback 3.5 3.7

Percentage of staff satisfied with the opportunities for 46% 51% flexible working patterns Percentage of staff experiencing physical violence from 3% 2% staff in last 12 months Percentage of staff experiencing harassment, bullying or abuse from patients, relatives or the public in last 12 33% 27% months Percentage of staff experiencing discrimination at work in 15% 12% the last 12 months

(Source: NHS Staff Survey 2016)

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The staff survey action plan 2017-18 was developed in April 2017 following the publication of the NHS staff survey (2016). The findings of the staff survey were shared with all staff across the trust. Divisions and departments were encouraged to address priority areas specific to their teams, with support from the organisational development team where appropriate.

The main priority highlighted in the staff survey action plan was to increase engagement through developing and improving the culture, leadership and communication across the trust. Three further priorities based on the lowest ranking scores included areas in patient care and experience; errors and incidents and violence, harassment and bullying. Progress against the action plan was monitored by the education and workforce sub-committee and the executive management team, and reported to the quality and safety committee.

The NHS staff survey (2017) had recently been published and summary findings were shared with staff through the trust newsletter. The staff response rate for the 2017 staff survey was 35%. This was in the lowest 20% of acute trusts in England (44%), and compared with a response rate of 39% in this trust in the 2016 survey.

The results from the NHS staff survey (2017) showed there had been some improvement in four areas highlighted as worse than average in the 2016 survey; support from managers, staff reporting errors, near misses or incidents, staff experiencing discrimination at work and staff satisfied with the opportunities for flexible working patterns. However, these were still below the average. The 2017 survey findings also showed the percentage of staff experiencing harassment, bullying or abuse from patients, relatives or the public in last 12 months had significantly improved since 2016 and the trust scored the same as national average for this indicator.

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 above the England average for recommending the trust as a place to receive care from Dec 2016 to August 2017 but scored similar to the England average from September 2017 to November 2017.

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(Source: Friends and Family Test)

The Friends and Family Test (FFT) responses were generally positive across the trust, with the exception of the accident and emergency care department. Response rates showed a large variation between wards and departments, with lower response rates seen in outpatients, day case areas and the accident and emergency care department.

An FFT action plan was developed to improve compliance in the emergency department and day case areas as well as trust-wide actions. Improvement actions included identifying FTT leads, use of volunteers and raised awareness and monitoring. The action plan was monitored through the patients’ first committee, which was a sub-committee of the quality committee.

Sickness absence rates

The trust’s sickness absence levels from September 2016 to August 2017 were higher than the England averages.

(Source: NHS Digital)

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Sickness rate reduction was monitored as part of the two year improvement programme to reduce trust absence to 4% by the end of March 2018. Targets were in place for each division and corporate department level with monthly reports showing progress against the target. The average sickness rate from April to December 17 was 4.53%, which had improved from over 5% in 2016 but was still worse than the trust target of 4%.

The trust’s plan to improve sickness and absence focussed on the two main areas that contributed to staff sickness / absence; mental health/stress and musculoskeletal conditions (MSK). There were a number of initiatives in place to improve support for staff including a staff wellbeing day with invited external support groups, occupational therapy referrals, mental health access to work support, a revised display screen equipment policy and physiotherapist support for staff.

Attendance management was a work stream as part of the workforce improvement programme board reporting monthly on progress with achieving corporate and divisional targets. The implementation of an updated new management of attendance and employee health and wellbeing policy and appointment of dedicated HR Attendance management officers to support divisional managers had also led to some improvement in sickness rates.

General Medical Council – National Training Scheme Survey

In the 2016 General Medical Council Survey the trust performed the same as expected for all indicators.

(Source: General Medical Council National Training Scheme Survey)

Governance There was a clear governance structure that supported the escalation of information and key risks to the trust board through various committees and assurance groups. The board and other levels of governance in the organisation functioned effectively and interacted with each other appropriately.

Governance systems had been reviewed and changed since the last inspection. The main sub- committees of the board were: -  Quality committee (monthly)  Finance and performance committee (monthly)  Partnerships Committee (monthly)  Workforce committee (every two months)  Major projects committee (every two months)  Remuneration committee (at least once annually)  Audit and assurance committee (every three months)

All sub-committees of the board were chaired by a non-executive director (NED) and had clear terms of reference. The NED’s were engaged in quality governance. They were sighted on most issues and provided appropriate challenge. The trust board and sub-committees received timely, detailed, high quality information through periodic reports, summary briefings and integrated dashboards to inform planning and decision-making.

There were also two additional executive led committees that fed in to the board of directors; the integrated governance and risk committee and the health and safety committee.

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Structures, processes and systems of accountability were in place to support the delivery of the strategy. There was a network of sub-committees and assurance groups that were led by executive directors that reported to the board committees. Executive team meetings were held on a weekly basis to support additional focus on strategy, recovery and delivery of key business cases at executive level. There were divisional management, patient safety and quality boards that linked in to the board committees.

The trust had commissioned an independent review of governance against the NHS improvement well led framework in April 2017. There had been 24 recommendations for improvement following the review and an action plan was put in place. The trust commissioned a follow up review of progress made against the recommendations from the April 2017 review. This highlighted that 20 of the 24 recommendations had been implemented, including improvements in the appropriate level of challenge from non-executive directors and engagement with governors. The trust was still progressing with the remaining four recommendations; to review supporting strategies so they are aligned with the overall clinical services strategy, to introduce data quality kite marks and to strengthen assurance around cost improvement quality impacts and workforce issues to the quality committee. The medical director and chief nurse attended the workforce committee and quality committee to ensure the quality committee was cited on workforce related risks.

The chief nurse was the executive lead for safeguarding adults and children. There were separate named safeguarding professionals designated for both adults and children’s and each were supported by a team of specialist practitioners and liaison nurses. The safeguarding leads met regularly with the chief nurse and deputy nurse to review policy, lessons to be learned from reviews both locally and nationally and the safeguarding agenda. There were audit programmes to ensure that safeguarding systems and processes were functioning effectively.

The trust board received an annual safeguarding report. There was an integrated safeguarding sub-committee that reported to the quality committee and was chaired by the chief nurse. There were separate adults and children’s safeguarding groups that reported to the safeguarding sub- committee. There was a separate safeguarding domestic abuse group until recently but this was incorporated into the adults safeguarding group. There was a clear structure to recognise and support safeguarding concerns within the trust. The safeguarding leads were aware of non- compliance with safeguarding training targets and had plans in place to improve this. There were effective support mechanisms with other agencies, such as the Police, local authorities and the local mental health trust.

The chief pharmacist was accountable to the medical director. The medicines safety officer (MSO) role was well embedded, and there were lines of escalation through the trust governance structure for incidents involving medicines. Performance of the pharmacy team was monitored through a range of key performance indicators. However the chief pharmacist was not required to formally report these to the trust board.

There was a clear governance structure in place for infection prevention and control processes across the trust. An annual Infection prevention and control (IPC) report was prepared by the director for infection and prevention control (DIPC) and submitted to the trust board. The DIPC also produced an IPC performance report every three months. IPC committee meetings took place on a monthly basis with input from associated groups (such as antimicrobial prescribing and decontamination). The IPC committee reported in to the patient safety sub-committee on a monthly basis and to the quality committee.

The current DIPC was due to retire at the end of February 2018. The chief nurse planned to take over the role of the DIPC after this date. The trust had also appointed a nurse consultant with lead responsibility for infection, prevention and control and sepsis management.

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Board assurance Framework

The trust provided their Board Assurance Framework, which details six strategic objectives within each and accompanying risks. A summary of these is below.

1. To provide outstanding care for our patients

2a. To deliver our financial plan

2b. To deliver our key performance targets

3. To deliver our key performance targets

4. To be a continually learning organisation

5. To collaborate effectively with local and regional partners

(Source: Trust Board Assurance Framework)

(Source: Trust Board Assurance Framework)

The board assurance framework (BAF) and corporate risk register set out the strategic risks that could impact on the delivery of the trust’s objectives. The BAF and corporate risk register were reviewed by the trust board and the executive team to provide assurance that the strategic risks and the controls in place to mitigate the risk were appropriate and effective. Individual risks on the BAF were also reviewed by sub-committees of the board for oversight. The board received assurance from the sub-committees every three months and undertook a review of all BAF risks every six months.

Key risks to the organisation were recognised by the trust leadership and this was represented on the board assurance framework. The BAF identified that: -

 The board had sufficient assurance for two of the six strategic objectives; to be a continually learning organisation and to collaborate effectively with local and regional partners.  Assurance for the objective ‘to be in the top 20% of employers in the NHS’ was recorded as not available because the trajectories for key performance indicators had not yet been set.  There was limited assurance for the objective; ‘to provide outstanding care for our patients’ because of clinical staff vacancies and because the benefits of the electronic patient record

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(EPR) could not be realised until full implementation and availability of reporting suite was available.  There was limited assurance for the objective ‘to deliver our financial plan’ because the run rate performance needed to significantly improve in order to sustain delivery against the plan.  There was limited assurance for the objective ‘to deliver our key performance targets’ because current trajectories indicated limited confidence in delivering the required standard. Recovery plans were in place for the contractual performance indicators for referral to treatment (RTT), emergency care standards and cancer wait times.

Management of risk, issues and performance The risk management strategy 2017 – 2020 articulated the trust’s approach to managing risks. The strategy was approved in November 2017 and outlined the roles and responsibilities of the trust board, board sub-committees and divisional and specialty-level staff in identifying, managing and monitoring risks to the organisation. The board of directors were accountable for risk management and were responsible for reviewing organisational risks through the corporate risk register and strategic risks through the board assurance framework.

The audit and assurance committee was responsible for assuring the board that systems were in place for effective and timely risk escalation and effective systems were in place to manage and report on the board assurance framework. Board committees were responsible for oversight and assurance of strategic risks within the board assurance framework. The integrated governance and risk committee was chaired by the chief executive and was the executive level committee for assurance of risk management.

There was a clear process for identifying and escalating risks from ward to board. Risks were identified and reviewed at ward specialty / department level on a monthly basis. Risks scored at nine or greater were then escalated for review at monthly divisional level meetings or to the corporate risk register if divisional leads felt unable to manage or address the risk themselves. The trust board reviewed a high level register of all risks graded at 15 or greater on a monthly basis.

The integrated governance and risk committee reviewed newly escalated and considered whether to accept them onto the corporate risk register. Corporate risk register risks scoring greater than 12 were reviewed monthly at the integrated governance and risk committee, and aligned to the board assurance framework.

Performance information and data was routinely reported to the board committees. This included performance dashboards, reports and progress reports relating to incidents, workforce data (such as training and recruitment and retention), and financial performance and improvement projects. This allowed the trust board to identify and take actions to mitigate risks. For example, performance data highlighted poor performance in the cancer wait time performance. A ‘deep dive’ review was carried out to carry out a detailed analysis and identify improvement actions. Findings from the review were reported at the finance and performance committee.

A risk management report was submitted to the quality committee every three months. This included performance information on patient safety and health and safety management and compliance.

Performance against national targets was a challenge for the trust and this was identified as a key risk on the corporate risk register and the board assurance framework. The trust had an urgent and emergency care improvement programme in place. The programme had been spilt into three work streams; emergency care access, emergency care flow and hospital flow and discharge. Progress was reported to the trust improvement committee, which was chaired by the divisional

20171116 900885 Post-inspection Evidence appendix template v3 Page 16 clinical director for medicine and integrated care. The chief operating officer also reported progress on the plan to the quality committee.

There was an executive-led process in place for the weekly tracking and escalation of performance against referral to treatment times, cancer wait times and emergency care standard targets. The trust was working with stakeholders where system pressures affected the trust’s performance.

The chief nurse reported monthly to the workforce committee on nurse staffing, in line with the NHS Hard Truths (2013) and National Quality Board Report (2013) requirements. This provided an overview of nursing staff vacancies and shift fill rates across the ward areas. Shift fill rate information was used to identify areas where there had been three consecutive months with less than 80% fill rate or where the fill rate was less than 70% in the current month for registered nurses. The report also included patient experience and harm data per inpatient ward displayed with the staffing fill rate information. The report highlighted the actions taken on wards with identified staffing shortfalls to minimise patient safety risks.

A monthly ward accreditation process was in place using a RAG (red, amber, green) rating process based on staffing levels and complaints, compliments, patient falls, pressure ulcers and infections.

The director of human resources (HR) submitted a workforce report to the workforce committee. This provided an overview of staffing vacancies, recruitment, turnover, mandatory training, appraisal rates and sickness / absence rates across the trust. The report highlighted shortfalls in medical and nursing staffing across the trust. This was reflected in our core service inspection findings. Safe staffing levels were maintained through the use of flexible staff working and use of bank, locum and agency staff. There were a number of initiatives to improve staff recruitment and retention, including how to attract staff to the trust, taking into account diversity, recruiting local people, working with local schools and universities to attract young people and creating new roles such as the nursing associate and advanced clinical practitioners.

The workforce report highlighted an overall mandatory training rate of 87%, with improvements in most core subjects. The workforce report highlighted that appraisal rates had decreased over the three months between October and December 2017, with an overall appraisal rate of 81% in December 2018. A number of actions had taken place to improve appraisal rates, including divisional improvement plans, support for managers, implementation of a simplified policy and procedure, new guidance for managers and appraises introduced and a refreshed intranet hub with access to appraisal information. Appraises drop in sessions had also been introduced. Trend analysis showed that overall appraisal rates had steadily and consistently improved over the past three years.

The risk management report to the January 2018 quality committee showed that blood transfusion issues had been the most frequently reported patient safety incidents during 2017, with 1,506 reported. This correlated with findings from our medical care core service inspection as we identified poor compliance in relation to blood transfusion training.

ProgRESS (programmed reviews of effectiveness, safety and sensitivity) was a rolling 24 month programme of planned reviews mapped against elements of the CQC fundamental standards. It was used to identify and investigate areas of concern, risks, opportunities for change and improvement, or, areas of best practice. The programme used a variety of qualitative tools and quantitative indicators to give an overall level of confidence of compliance. Outcomes were reviewed and tracked by the CQC Steering Group and a separate update report was sent to the quality committee every three months. A progRESS responsive review was carried out to review patient records after we highlighted concerns during the core service inspection. The trust also used this process to carry out a ‘progRESS in a day’ review to gain assurance in several core

20171116 900885 Post-inspection Evidence appendix template v3 Page 17 services in December 2017. This was a ‘mock’ CQC inspection that involved staff, stakeholders and governors and the findings correlated with our findings during the core service inspection.

The trust had a quality improvement programme in place and used various sources to determine the priorities of its improvement, including complaints report, incident reports and feedback from patients. There had been 350 staff trained in the quality Improvement methodology during 2017. A number of quality improvement projects and collaborative took place across the trust, including the mortality review programme, deteriorating patient collaborative programme, safer surgical procedures, pressure ulcers, medicines safety, safety huddles, NHS Quest and the national maternal and neonatal health safety collaborative.

The safer surgical procedures programme aimed to continue to achieve above 95% compliance with the World Health Organization (WHO) checklist in all areas where invasive procedures take place by March 2019. As part of the programme the trust had implemented monthly WHO checklist audits, developed local standards, re-designed the WHO checklists, conducted observations of theatre teams to share learning and carried out staff culture survey. WHO checklist audits across the trust had been consistently above 98% over the past year; however, we observed poor practice by theatre teams in the obstetric theatre during core service inspection.

The improvement programme for safety huddles highlighted that 40% of wards and departments were currently doing safety huddles. The programme aimed to get all clinical areas doing this as part of daily routine within the next year.

The pressure ulcers improvement programme aimed to reduce the number of hospital acquired pressure ulcers on the collaborative wards by achieving 100 days ulcer free by 40% by 2019. As part of the programme the trust had carried out a number of improvements including standardised documentation to support pressure ulcer prevention, delivered pressure ulcer prevention training for newly appointed ward staff, improved access and visualisation of pressure ulcer data and introduced a pressure ulcer prevention metric as part of the ward accreditation assessment system.

Delayed transfers of care were consistently under 2% between October 2017 and March 2018. This was better than the national target of 3.5%.

Finances Overview

Historical data Projections Previous Last Financial This Financial Next Financial Financial metrics Financial Year Year (2016/17) Year (2017/18) Year (2018/19) (2015/16) Income £370.0m £393.5m £400,1m £408.1m

Surplus (deficit) (£6.5m) £1.8m (£11.2) £7.6m

Full Costs (£376.5m) (£391.7m) (£411.2m) (£400.5)

Budget (or budget (£3.5m) £9.0m (£11.0m) £7.6m deficit)

(Source: Routine Provider Information Request (RPIR) – Finances Overview)

The delivery of the financial plan was a strategic objective and the trust board identified financial performance as one the top risks to the organisation. This was reflected in the board assurance

20171116 900885 Post-inspection Evidence appendix template v3 Page 18 framework and the corporate risk register. The board had a good understanding of the current financial position and the challenges and risks to the trust in the current year and during 2018/19. Financial performance was reviewed on a monthly basis at the finance and performance committee.

NHS improvement (NHSi) reported that the trust had a good track record of ensuring delivery of overall financial plans. The trust achieved the financial plan and exceeded the control total in 2016/17. The trust also achieved its cost improvement programme (CIP) plan on a recurrent basis in 2016/17.

The trust’s 2017/18 financial control total in the revised financial plan submitted in March 2017 was a deficit of -£7.8m and the maximum available sustainability and transformation funding (STF) was £9.8m, resulting in a post-STF control total surplus of £2.0m. Delivery of this plan was dependant on the trust delivering financial efficiencies and cost improvements of £20.2m during 2017/18.

The finance report to the January 2018 finance and performance committee reported that the trust delivered a pre-STF deficit of £7.8m at the end of January 2018 (Month 10). The revised improvement plan forecasted a pre-STF deficit £7.9m, which meant the trust was in line with the improvement plan trajectory up to January 2018. However, the trust was £5.3m behind the cumulative post-STF control total.

The forecast for end of year (March 2018) was to achieve the pre-STF control total of -£7.8m. NHSi reported they had received reasonable assurance that the financial plan would be delivered, although this was dependant on finalised agreement with the local commissioners and the trust managing to manage the cost of winter within its forecast. The director of finance reported that they planned to identify non-recurrent measures to improve the forecast for February and March 2018. The trust was attempting to mitigate risks relating to income estimates by agreeing total year end income figures with key commissioners. The trust had recently commissioned an external consultancy partner to support service and financial improvement.

The trust had exceeded the agency spending cap in January 2018 and the forecast for full year agency spend was £15m to £15.7m, which was worse than the full year ceiling of £12.3m. This reflected our findings in relation to staffing vacancies and use of agency staff during the core service inspection.

The trust’s CIP plan was in place to deliver £24.4m of efficiencies by March 2018. There was an extensive quality improvement programme in place across the trust. A

A combined impact assessment (CIA) screening tool was completed for all improvement programmes and for projects that were likely to directly or indirectly impact on quality of services. The CIA screening tool considered five types of risk:-

 Risks to the quality of care provided (quality impact). Identified risks were required to be added to the divisional risk register for monitoring. Any significant risks resulted in the completion of a full Quality Impact Assessment (QIA).  A full financial impact assessment was required where the programme or project was likely to have a financial impact of +/- £50,000.  Potential risks to staff motivation and morale (colleague impact).  Risk of discrimination to any protected characteristics groups / health inequalities or impact upon human rights (equality impact).  Risks relating to the use of patient or sensitive staff information (privacy impact).

The CIA screening tool used a scoring system where scores greater than 12 required completion of a full quality impact assessment requiring review and sign-off by the chief nurse and medical director for consideration before the proposed change can proceed. There had been 35 CIA screens completed across eight programmes, resulting in two full quality impact assessments. We 20171116 900885 Post-inspection Evidence appendix template v3 Page 19 reviewed one completed quality impact assessment and this had been appropriately reviewed and approved.

Proposed Overall Risk Rating Principal Risk Initial Residual Target Current Direction Current 1 Failure to maintain the quality of 16 8 4 12 ↑ Minimal patient services 2 Failure to sustain an effective 15 6 4 12 ↑ Minimal and engaged workforce 3 Failure to maintain operational 20 6 6 16 ↑ Cautious performance 4 Failure to maintain financial 16 12 6 16 ↑ Cautious sustainability 5 Failure to deliver the required 12 8 8 8 ↔ Open transformation of services 6 Failure to achieve sustainable 12 6 6 15 ↔ Cautious contracts with commissioners 7 Failure to deliver the benefits of 12 9 9 9 ↔ Open strategic partnerships Trust corporate risk register

Details of the trust most high profile risks are provided below:

Principal risk category 1: Failure to maintain the quality of patient services Risk ID Description score (current) There is a risk that The Trust is not responding to complaints in a timely manner and ensuring that there is evidence of recommendations being 3057 15 implemented within the Datix system. The impact is poor patient experience and reputation. There is a high risk that patients with alert organisms will not be isolated or have other appropriate management leading to increased cross 3060 15 infection to others due to the lack of a fully functioning infection control reporting system.

Principal risk category 2: Failure to sustain an effective and engaged workforce Risk score ID Description (current) There is a risk we will not be able to safely staff the wards due to 2995 vacancies and increased sickness absence resulting in a failure to 20 maintain safe nurse staffing levels. Ability to recruit and deploy adequate medical staff throughout the day to 2908 15 manage the demands of the Accident & Emergency Department.

Principal risk category 3: Failure to maintain operational performance Risk ID Description score (current)

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EPR-Reduced productivity and activity from staff whilst training and 2892 20 implementation of the EPR system is completed. There is an increased risk of cyber security attacks to healthcare organisations. Health records and healthcare providers are at risk of 3013 15 cyber-attack as demonstrated in recent examples. This could potentially cripple the clinical and business operations of the Trust. A structural survey and report was commissioned by E&F to determine the structural integrity of the floors of E Block. This was due to the amount of medical records stored in the building.

The report has found that the floors are significantly understrength for 3142 15 the current usage of the building and recommends immediate structural repairs / works to support the floors. This will cost a significant amount of money and to do the works, records and staff need to vacate the building. The building is a listed building so permission would need to be sought from the Local Authority. Costs will be in the region of £200k.

Principal risk category 4: Failure to maintain financial sustainability Risk ID Description score (current) EPR-inability to achieve the expected £5m FYE benefits realisation due 2893 20 to a delay in ‘go live’.

The Trust has insufficient cash & liquidity resources to sustainably 3012 16 support the underlying income & Expenditure run rate. Failure to maintain financial stability and sustainability in the current economic climate with the organisation facing continued cost inflation, 2150 16 tariff deflation, regulatory change, increased demand on services and a predicted curtailment of CCG growth funding. The requirement to maintain equilibrium between financial sustainability and delivering safe quality services is compromised by the economic 2151 16 challenge faced and the increasing internal and external demands to improve the quality and safety of the services provided.

Principal risk category 5: Failure to deliver the required transformation of services Risk ID Description score (current) There is a risk that the Sustainability & Transformation Plan (STP) for West Yorkshire & Harrogate, (incorporating the STP for Bradford districts and Craven), and the system wide financial instability, leads to enforced actions (e.g. changes in pathways of care or consolidation of 3091 12 support services) which the Board might consider are not in the best interests of the local patient population or which could create clinical, financial, operational or other regulatory difficulties for BTHFT, including the ability to deliver CIPs and meet control totals.

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Principal risk category 6: Failure to achieve sustainable contracts with commissioners Risk ID Description score (current) Recruiting and securing contractors in the Business Intelligence (formerly Corporate Information) difficult in the region. Contractual 2561 16 reporting and day-to-day operational information may be impacted. Ability to support performance and improvements can be challenging Failure to deliver the obligations within the NHS standard acute contract will result in the application of financial penalties and/or the failure to recover planned income. This will include a failure to deliver specific 2157 indicators relating to specific targets/qualitative requirements and/or 15 failure to deliver agreed indicators within the CQUIN schedule. The qualitative nature of the indicators will adversely impact on both the quality of services provided and the patient experience. EPR - Inability to fulfil contractual obligation in relation to information, reports, standards etc. following implementation of EPR. Loss of 2991 15 confidence in the Trust from other healthcare organisations leading to damage to organisational reputation.

Principal risk category 7: Failure to deliver the benefits of strategic partnerships Risk ID Description score (current) We are unable to develop and maintain positive relationships with our 3037 key external partners, which inhibits vertically and horizontally integrated 9 care pathways.

(Source: Trust Corporate Risk Register)

The integrated governance and risk committee reviewed newly escalated and considered whether to accept them onto the corporate risk register. Corporate risk register risks scoring greater than 12 were reviewed monthly at the integrated governance and risk committee, and aligned to the board assurance framework.

We reviewed the corporate risk register and found this was up to date and completed appropriately. Risks included date of addition to register and review dates. Each risk was assigned to an executive director as the lead with accountability for the risk. An action plan lead was also assigned to each risk. The mitigating actions were frequently updated to record the activities taken to mitigate risks. Risk scores were updated and appeared to be consistent with the level of risk and mitigating actions recorded. The priority risks on the corporate risk register reflected the risks on the board assurance framework. The risks detailed in the register were reflective of those highlighted to us by staff and broadly correlated with our findings during the inspection.

Information management The board and its sub-committees received suitable information in order to gain assurance on implementing the trust’s strategic objectives and operational and financial performance. Board and committee papers provided detailed information through a combination of progress reports, meeting minutes and performance dashboards.

The trust had developed a series of performance dashboards to enable appropriate oversight and challenge. A series of dashboards were in place and these provided monthly updates to the board and its committees. The dashboards were customised depending on the committee reported to.

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For example, there was a separate quality dashboard, finance and performance dashboard and workforce dashboard. There was a RAG (red, amber, green) rating system for key indicators and a performance chart showing trends over the past three years. Many of the indicators were benchmarked either nationally or locally to help monitor and improve performance and outcomes.

The trust had effective arrangements to ensure that data or notifications were submitted to external bodies as required. Incidents, including serious incidents, were reported as required to the NHS national reporting and learning system or the NHS strategic executive information system.

Staff across the trust could access information through meetings, updates, newsletters and through the trust’s intranet site. Policies and procedures were available on the trust intranet. We found some policies had gone past their review date during the maternity and medical care core service inspections. This was highlighted in the quality committee dashboard. The director of governance and corporate affairs reported there was an on-going plan to review and update all policies. We found evidence of information available for patients and the public during our core service inspections; however ward performance and safety thermometer information was not publicly displayed in the majority of areas we inspected.

The trust launched an electronic patient record (EPR) system in September 2017. This was developed in partnership with Calderdale and Huddersfield NHS Foundation trust. There was a comprehensive implementation plan and support functions available during the implementation to ensure the EPR system was implemented across most areas of the trust without significant problems. The system enabled staff within the trust and externally (such as community staff and GP’s) to access patient records remotely. The EPR system also included electronic prescribing.

The trust aimed to operate as a paperless organisation. However, there were still some services (such as maternity) that operated paper-based records or legacy IT systems in conjunction with the EPR. Our discussions with staff during focus groups and core service inspections highlighted that most staff were positive about using the system. They felt using the system meant there was a delay in providing care and treatment compared with paper records but saw the benefits of improved accessibility to patient information. Staff accessed the system using secure key card access.

There were some on-going issues related to productivity following the implementation of the EPR in the accident and emergency, endoscopy and outpatients areas. There were improvement actions in place to address this and progress was monitored weekly by the chief operating officer and routinely reported to the finance and performance committee. Improvement actions included additional support and training for staff and the use of additional clerical staff.

The EPR system had reporting functionality which allowed staff to generate reports covering a range of information, such as performance data and patient access and flow information. The trust was still developing a report for endoscopy services and activity reporting. Where EPR reporting functionality was not available, staff were able to obtain the relevant information manually.

The trust had completed the information governance (IG) toolkit 2017/18 requirements were assessed each month by the IG sub-committee. Information governance training compliance for staff across the trust was 87% in December 2017 is 87%. This was below the target of 95% compliance by March 2018. A review of non-compliant staff was carried out and circulated to management teams in order to improve compliance.

Information governance was reported to the quality committee on a monthly basis. There was an information governance dashboard that included incidents, reportable incidents, security breaches and updates of IG training. Information governance incidents (records errors, confidentiality and information security breaches) were reported using the trust incident reporting system and reviewed and rated using the NHS Digital grading tool. The trust reported three high risk (level 2)

20171116 900885 Post-inspection Evidence appendix template v3 Page 23 incidents during 2017 and these were reported to the Information Commissioner's Office (ICO). The trust’s information governance arrangements were reviewed by ICO best practice team in November 2016. There were a total of 50 recommendations and these had been completed with a report sent to ICO in December 2017.

Engagement Most staff reported that the leadership team were visible and approachable. The executive and non-executive directors undertook a scheduled programme of walkabouts across the directorates and reported these back at board meetings. Staff engagement took place through a variety of methods, including focus groups, staff surveys, listening events, correspondence update and newsletters. The trust launched the ‘Let’s Talk’ engagement programme in July 2017: -

 ‘Let’s Talk about us’ involved staff led focus groups, questionnaires, ‘walk the wards’ and briefings to engage staff about the trust values and behaviours  ‘Let’s Talk: live’ was an opportunity for staff to have informal discussions with the chief executive or to raise issues and concerns.  ‘Let’s Talk hub’ was an intranet set for key resources.  ‘Let’s celebrate’ was a monthly and annual staff rewards and recognition scheme.  ‘Time2talk’ was an online resource focused on having effective appraisals and regular one to ones.  ‘Let’s Talk together’ was a senior leaders timeout day held every three months.

The national NHS staff survey (2016) showed the trust scored 3.75 (out of five) for an overall indicator of staff engagement. This was below average (3.81) when compared with other trusts of a similar type. The national NHS staff survey (2017) findings showed the trust scored 3.82 for staff engagement, which had improved since the previous survey and was better than the average of other acute trusts (3.79).

We received a mixed response from black, asian and minority ethnic (BAME) and disability network representatives in relation to engagement and involvement from the trust leadership. Both groups told us the trust viewed them as experts in their area and they were supported by the trust board. However, the BAME network representatives told us the network used to have a sponsor within the trust at director level that had left. They told us the board approved of providing a sponsor but at this time the network had been waiting for a year for one to be appointed.

There was a staff side committee in place. Members we spoke with told us they had a good working relationship with the executive team and they felt they were listed to. Members told us they had limited engagement with the chief executive but they met with the director of HR on a regular basis.

Board members actively engaged with the governors and members of the trust. Governors we spoke with were actively involved with the trust and received regular updates on how the trust performed. Governors were invited to attend board meetings and walkabout visits. The chair and deputy chair regularly met with governors.

The chief pharmacist reported that there was positive and collaborative engagement with external partners. For example, the chief pharmacist was a member of the West Yorkshire Acute Trust network. There was patient representation on both the medicines safety group and the drug and therapeutics committee. Staff were actively engaged in discussions about service performance and development, for example a recent staff consultation had been carried out on proposals for seven day working

The trust routinely engaged with patient and the public engagement. The patient’s first sub- committee had processes in place to capture, record and action patient feedback from a range of

20171116 900885 Post-inspection Evidence appendix template v3 Page 24 sources such as Friends and Family Test, complaints and patient engagement groups. The assistant chief nurse was the patient experience lead. Examples of engagement included: -

 Patient stories were presented at board meetings. Patients were invited to attend board meetings and this was used an opportunity for staff to improve services.  The ‘Wayfinding Strategy: representation enhanced insight into needs of people with dyslexia, dementia & sensory loss, which impacted on design decision making throughout.  Public representation in the parking strategy influenced decisions on the number and location of disabled parking spaces needed to improve access and safety.  The increased diversity of ‘patient-led assessments of the care environment’ (PLACE) patient assessors to assess specific issues such as access led to improved provision of hand-rails.  There was patient representation on both the medicines safety group and the drug and therapeutics committee.  Patient and carer input was sought during the cardiology improvement project  John’s Campaign was a patient / relative engagement influenced decision to implement its principles more widely and not just patients living with dementia.  The EPR patient portal workshop was used to improve the initial design and functionality of this platform.

The trust routinely engaged and collaborated with other healthcare providers. The trust was a member of the West Yorkshire and Harrogate Sustainability and transformation plan (STP) and worked with other trusts within the West Yorkshire Association of Acute Trusts (WYAAT). The regional imaging collaborative group consisted of the STP trusts as well as NHS trusts from North and East Yorkshire to jointly develop a regional solution for imaging. The trust provided services in stroke, renal medicine and medical oncology for Airedale NHS Foundation Trust and also had joint-venture arrangements for pharmacy and pathology services. The electronic patient record (EPR) had been developed and implemented as a joint product with Calderdale and Huddersfield NHS Foundation Trust.

The trust routinely engaged with local commissioners, NHS improvement and Bradford care alliance (local GP service representatives). Commissioners and local GP’s had attended ‘Let's Talk Live’ engagement forums to both participate and present to the trust. Feedback from stakeholders we spoke with demonstrated there was positive engagement from the trust.

Learning, continuous improvement and innovation The virtual ward commenced in 2012. The service was aimed at avoiding unnecessary admissions and readmissions to hospital, and promoting/supporting earlier discharge from hospital. The service was designed for patients aged 65 and over with complex care needs such as frailty and dementia that were medically stable but required a multidisciplinary approach to support maximising independence and function.

The service was led by a geriatric medicine consultant and a nurse consultant, supported by various multidisciplinary staff including advanced nurse practitioners, nurses and therapy staff. Patients received care in their usual place of residence or, when required, in a community hospitals and local authority bed setting.

There were clearly defined referral and discharge pathways and admission criteria for patients that could access this service. There had been 737 patients referred to the service from acute wards between April 2017 and October 2017. Patients could access the service on the day of referral. Information supplied by the trust showed that since the virtual ward commenced there had been a steady reduction in patient length of stay and average bed occupancy in the elderly medicine specialty while the number of admissions had slightly increased during this period.

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The trust aimed to expand the concept through the establishment of further ‘virtual’ services, such as a virtual fracture clinic, virtual diagnostic ward and virtual paediatric ward in the future.

The ‘organisational learning response system’ was used as a learning process to support trust- wide change and improvement and contribute to the avoidance of future incidents. The system enabled precursor incidents (such as complaints, incidents, inquests, mortality reviews and patient experience information) to be used in a learning process to support trust-wide change and improvement and contribute to the avoidance of future incidents. Learning was disseminated or actioned through alerts, newsletters, safety information dissemination, information about action taken and descriptions of local improvement actions.

The pharmacy directorate took part in a number of benchmarking activities to compare performance with other trusts, for example the medicines safety thermometer, model hospital and NHSI benchmarking. There was limited evidence of service improvement based on benchmarking results.

The trust actively participated in research activities and there were good examples of continuous learning, improvements and innovations. This included: -

 The trust won the Won the national EHI Healthcare Product Innovation Award and the Royal College of Physicians Excellence in Patient Care Outstanding IT Innovation Award for the Electronic Frailty Index.  The BabyView video link system won at the 2016 Patient Experience Network National Awards (PENNA).  The trust was the winner of NHS Improvement’s inaugural “Sir Peter Carr Award” for the ‘15 seconds: 30 minutes’ initiative. This encourages staff to complete small tasks today that may take 15 seconds but could save a colleague 30 minutes by avoiding further work downstream.  The trust was one of the few centres in the north of England offering robotic partial nephrectomy surgery and robotic radical cystectomy surgery.  The new hospital wing opened during 2017 and the trust was awarded the best public service building category at the Local Authority Building Control, West Yorkshire Region, and Building Excellence Awards.  The trust implemented the electronic patient record system (EPR) during September 2017.  The joint care model of surgeon and geriatrician supported by a dedicated fragility nurse has contributed significantly to improved outcomes for fracture neck of femur patients.  Project SEARCH was a year-long pre-employment programme, based at the trust, for young adults with a learning disability. Last year’s employment outcomes for Project SEARCH reached 66.7%.

Mortality Review Process Overview The mortality sub-committee (reporting to the quality and safety committee) had oversight of mortality across the trust and oversaw the mortality review improvement programme. There was a mortality review improvement group, mortality data surveillance review group and a learning disabilities mortality review group that reported to the mortality sub-committee.

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There was evidence of learning from the death of patients, and support given families and carers through any investigation process. The trust had reviewed the 2017 NHS National Quality Board guidance on Learning from Deaths and the 2016 CQC report ‘Learning, candour and accountability’. The trust had produced a local policy on learning from mortality and reports about mortality were submitted to the trust board every three months. The trust was also developing links with other care providers in Bradford to share information and learning around mortality.

The mortality review improvement programme started in October 2016. This required all staff involved in case note reviews to undertake mortality reviews using the Structured Judgement Review (SJR) method. The trust had trained 170 doctors and senior nurses to conduct reviews using the SJR process. The target for completion of mortality reviews using the SJR method was 25%. There were163 mortality reviews (13%) completed up to January 2018. The number of mortality reviews completed had reduced since the introduction of the electronic patient record (EPR) in September 2017 but had steadily improved since.

We reviewed a selection of mortality investigation reports during the inspection and these were completed appropriately. Learning from mortality reviews was shared through the circulation of a mortality dashboard and mortality outcomes report across the trust. A summarised update was recently been circulated using the ‘learning matters’ communication. Key themes and trends identified from the mortality reviews were shared with staff, including where areas of good practice were identified.

The mortality data surveillance review group reviewed performance against mortality indicators on a monthly basis. The Summary Hospital-level Mortality Indicator (SHMI) placed the trust in the “as expected” category with an outcome of 93. This refers to the twelve months July 2016 to June 2017. The Hospital standardised mortality ratio (HSMR) was 87 in the 12 months October 2016 to September 2017. This placed the Trust in the “better than expected” category. This had been steadily reducing during 2017. The medical director told us improvement in the HSMR and SHMI mortality indicators was due to a number of factors, such as increased presence of consultants and a focus on consultants treating acutely ill patients.

Serious incident Process Overview There were clear processes in place for the reporting, investigation and learning from incidents. Reported incidents, complaints and patient deaths were reviewed at weekly quality of care panel (QuoC) meetings attended by the medical director and the assistant director of governance and risk. The panel identified serious incidents that required formal investigation. Serious incident investigations were allocated to independent consultant or nursing staff.

Incidents were also reviewed at weekly integrated performance and governance (IPMG) meetings. A monthly serious incidents report was submitted to the quality committee. This listed the serious incidents raised during the previous month along with identified trends and details of improvement actions taken.

We looked at seven serious incident investigations completed during 2017. These were completed to a good standard and contained appropriate information, action plans and evidence of learning and improvement. There was evidence of comprehensive investigations having been undertaken with root cause analysis, chronology (timeline of events) and a review of business continuity arrangements recorded. The incident reports detailed the involvement and support provided for staff involved in the incident as well as support for patients and relatives (such as duty of candour principles). The reports included a section to record 'notable practice' which highlighted good practice identified during the investigation. The reports also identified the arrangements for shared learning and circulation across the trust. Action plans had lead responsibilities and completion dates recorded.

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Learning from incidents was shared across the trust in a variety of ways; through the incident reporting system, through rapid response alerts and staff newsletters, such as the monthly ‘Learning Matters’ and the ‘Responding and Improving’ newsletter (every three months). Learning was also discussed on an individual basis with those who may be directly involved with incidents and with a range of staff through daily safety huddles and team, directorate and divisional level meetings.

Complaints process overview

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 86.5%

What is your target for completing a complaint 30 53% Negotiated If you have a slightly longer target for complex complaints with N/A please indicate what that is here complainant Number of complaints resolved without formal process in the 1,069 09/16 - 09/17 last 12 months?

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

Number of complaints made to the trust

The trust received 593 complaints from October 2016 to September 2017. Surgery core service received the most complaints with 222.

Number of Core Service Percentage of total complaints Surgery 222 37%

Medical care 103 17%

Outpatients 103 17%

Urgent and emergency services 69 12%

Other 31 5%

Gynaecology 22 4%

Services for Children and Young People 20 3%

Maternity 13 2%

Diagnostics 9 2%

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End of life care 1 0%

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

An internal audit report into complaints handling and learning to improve was published in August 2017. Overall processes were found to be satisfactory. The auditors had significant confidence in each aspect of the service including policies and procedures, compliance, training, oversight of performance and lessons learnt. The report made six recommendations for improvement including further training for staff involved in writing complaint responses and improvement in timeliness of correspondence to complainants. Implementation of actions was overseen by a complaints steering group.

A complaints trajectory improvement plan was presented to the executive team in November 2017. This highlighted the response rate to responding to complaints within 30 days was 58%. The response rate had improved since September 2017 (53%). The improvement plan identified the number of complaints that needed to be resolved each week by the divisions in order to maintain ongoing activity and resolve the complaint backlog over a 12 week period. The trajectory was based on the number of complaints received in the last two years and included the back log of complaints per division.

A complaints’ summary was compiled each week by the central complaints team. This was reviewed at the weekly quality of care panel (QuoC) and included detail about new complaints raised and whether a risk incident had been raised for the complaint.

The management of complaints was discussed at monthly divisional performance meetings. Each division submitted improvement action plans to the chief nurse; the action plans were managed by the divisions and monitored by the central complaints team. Non-compliance against the actions was monitored by the patient experience manager, with escalation to the chief nurse as required.

A patient experience report was presented at the quality committee every three months. This report included a breakdown of complaint numbers by division, an analysis of complaint reasons, timeliness of complaint responses, complaint outcomes and details of lessons learnt from complaints. The board of directors received a monthly update on complaints performance at each monthly meeting through the integrated performance dashboard and key summary of complaints data through the report from the quality committee every three months. An annual complaints and Patient Advice and Liaison Service (PALS) report was also reviewed by the trust board.

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:

Accreditation scheme name Service accredited Endoscopy unit accreditation was granted for Joint Advisory Group on Endoscopy (JAG) the year 2016 on 8 Oct 2016, this is because we had not achieved the required GRS levels to complete the annual card Clinical Pathology Accreditation and its Due to the recent departmental re-structuring successor Medical Laboratories ISO 15189 the laboratory sections in Pathology are not 20171116 900885 Post-inspection Evidence appendix template v3 Page 29

accredited by either CPA or ISO15189. The Pelvic Health Unit has accreditation from Accreditation from the British Society of the British Society of Urogynaecology, one of Urogynaecology only 8 centres to be accredited. Successfully achieved re-accreditation to 2008 ISO 9000 - Medical Physics standard 2.2.17 ISO 9000 - Estates Project Management Successful accreditation and assimilation to new ISO 9000 - 2015 standard (complete Jan 17)

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

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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 trust has one emergency department, based at Bradford Royal Infirmary. This provides 24 hour comprehensive accident and emergency service including resuscitation and high dependency (HDU) service, dedicated paediatric service and co-located GP service.

(Source: Trust website)

Activity and patient throughput

Total number of urgent and emergency care attendances at Bradford Teaching Hospitals NHS Foundation Trust compared to all acute trusts in England

There were 135,147 attendances from April 2016 to March 2017 at Bradford Teaching Hospitals NHS Foundation Trust as indicated in the chart above.

(Source: NHS England)

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Urgent and Emergency Care attendances resulting in an admission

The percentage of A&E attendances at this trust that resulted in an admission was stable from 2016 to 2017. In both years, rates were higher than the England averages.

(Source: NHS England)

Urgent and Emergency Care attendances by disposal method

* Admitted to hospital 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)

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

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Mandatory training completion rates

The trust set target rates of 75% and 95%, on a course by course basis, for the completion of mandatory training.

A breakdown of compliance for mandatory courses from April 2016 to March 2017 for medical/dental and nursing/midwifery staff in urgent and emergency care is shown below. All staff were based at Bradford Royal Infirmary.

Medical and dental staff

Staff Staff Completio Trust Target Course title trained eligible n rate Target met? Introduction to Equality & Diversity - General 25 25 100% 95% Yes Acute Kidney Injury (AKI) - General 7 7 100% 75% Yes Infection Control - No Renewal 52 54 96% 95% Yes Communication Improvement using the SBAR Technique - General 18 19 95% 75% Yes NEWS/PAWS/NeoNate Observation Theory - General 18 19 95% 75% Yes Diabetes Care and Safe Use of Insulin - General 16 17 94% 75% Yes Safe Administration and Preparation of Injectables - General 15 17 88% 75% Yes Corporate Induction 49 54 91% 95% No Information Governance - 1 Year 49 54 91% 95% No Moving & Handling Low Risk - General 47 54 87% 95% No Fire Safety - 2 Years 13 15 87% 95% No Health and Safety - 2 Years 41 54 76% 95% No Blood Transfusion - 1 Year 12 18 67% 75% No Fire Safety - 1 Year 25 39 64% 95% No Infection Control - 1 Year 9 19 47% 95% No Adult Basic Life Support - 1 Year 8 19 42% 75% No

The overall completion rate for medical and dental staff in urgent and emergency care was 83%. The trust failed to meet their target for nine of the 16 courses.

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Nursing and midwifery staff

Staff Staff Completio Trust Target Course title trained eligible n rate Target met? Strategic Risk Management 1 1 100% 75% Yes Dangers of Misplaced Naso Gastric (NG) Tube (NPSA Alert) - General 1 1 100% 75% Yes Infection Control - No Renewal 87 87 100% 95% Yes Corporate Induction 87 87 100% 95% Yes Equality & Diversity for Managers- General 1 1 100% 95% Yes Communication Improvement using the SBAR Technique- General 80 85 94% 75% Yes Safe Administration of Medicines - Competence Assessment- General 51 56 91% 75% Yes Blood Transfusion - 1 Year 30 33 91% 75% Yes NEWS/PAWS/NeoNate Observation Theory - General 75 83 90% 75% Yes Safe Administration of Medicines - 2 Year 72 80 90% 75% Yes Diabetes Care and Safe Use of Insulin- General 64 74 86% 75% Yes NEWS/PAWS/NeoNate Observation Competence Assessment- General 63 80 79% 75% Yes Venous Thromboembolism - No Renewal 62 82 76% 75% Yes Introduction to Equality & Diversity - General 102 110 93% 95% No Information Governance - 1 Year 66 87 76% 95% No Fire Safety - 1 Year 66 87 76% 95% No Adult Basic Life Support - 1 Year 60 85 71% 75% No Infection Control - 1 Year 60 87 69% 95% No Acute Kidney Injury (AKI) - General 2 3 67% 75% No Conflict Resolution - 3 Years 56 85 66% 95% No Moving & Handling Medium/High Risk- General 52 79 66% 95% No Health and Safety - 2 Years 54 87 62% 95% No Moving & Handling Low Risk - General 53 87 61% 95% No Preparing to Administer/Administering Blood - 3 Year 38 71 54% 75% No Organising Receipt of Blood - 3 Year 37 71 52% 75% No

The overall completion rate for nursing and midwifery staff in urgent and emergency care was 78%. The trust failed to meet their target for 12 of the 25 courses.

(Source: Routine Provider Information Request (RPIR) P40 – Statutory and Mandatory Training)

The role of the professional practice and development lead for the emergency department was compliance with mandatory training. As part of this role, the practice development lead arranged “sweeper” days in which mandatory and other training was planned as part of the staff rota. In practice the hours allocated as available for mandatory training were limited by the availability of staff. Medical and nursing staff we spoke with told us mandatory training associated with the introduction of the electronic patient record in September 2017 had adversely affected the completion of other mandatory training. The trust provided mandatory training figures current at the time of our inspection. The overall

20171116 900885 Post-inspection Evidence appendix template v3 Page 34 completion rate for the emergency department as at 10 January 2018 was 82.21%. For basic life support, the completion rate as at 10 January 2018 was 61.54%. The practice development lead explained that there was often a delay between training completion and it being represented in training completion figures. Each member of staff we spoke with was aware the emergency department was not compliant with trust standards for the completion of mandatory training in all areas. However, all staff we spoke with confirmed they had completed their mandatory training within the last 12 months, or an arrangement was already made for them to attend training. The practice development lead told us that training for medical staff was included in the staff rota and that the emergency department liaised with other departments to facilitate training and cross skilling such as with radiology.

Safeguarding

Safeguarding training completion rates

The trust set a target rate of 95% for the completion of safeguarding training.

A breakdown of compliance for safeguarding courses from April 2016 to March 2017 for medical/dental and nursing staff in urgent and emergency care is shown below. All staff were based at Bradford Royal Infirmary.

Medical and dental staff

Staff Staff Completio Trust Target Course title trained eligible n rate Target met? Safeguarding Children Level 2 - 3 Years 19 20 95% 95% Yes Safeguarding Children Level 1 - 3 Years 49 54 91% 95% No Safeguarding Adults Level 1 - 3 Years 45 54 83% 95% No Safeguarding Children Level 3 - 1 Year 14 19 74% 95% No Safeguarding Adults Level 2 - 3 Years 0 3 0% 95% No

The overall completion rate for medical and dental staff was 85%. The trust failed to meet their target for four of the five courses.

Nursing and midwifery staff

Staff Staff Completio Trust Target Course title trained eligible n rate Target met? Safeguarding Children Level 2 - 3 Years 87 87 100% 95% Yes Safeguarding Children Level 1 - 3 Years 87 87 100% 95% Yes Safeguarding Adults Level 1 - 3 Years 84 87 97% 95% Yes Safeguarding Adults Level 2 - 3 Years 82 87 94% 95% No Safeguarding Children Level 3 - 1 Year 72 81 89% 95% No Safeguarding Adults Level 3 - 3 Years 1 2 50% 95% No Safeguarding Children Level 3 Specialist - 1 Year- General 1 2 50% 95% No

The overall completion rate for nursing and midwifery staff was 96%. The trust failed to meet their target for four of the seven courses.

(Source: Routine Provider Information Request (RPIR) P40 – Statutory and Mandatory Training)

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The trust provided safeguarding training completion figures current at the time of our inspection. The overall completion rate for the emergency department as at 10 January 2018 was 78.67%. Each member of medical and nursing staff we spoke with confirmed they had completed their mandatory safeguarding training within the last 12 months, or an arrangement was already made for them to attend training. Staff we spoke with told us that the trust also provided themed training days for staff with specialist speakers and up to date information in respect of legislative changes or additions. A senior consultant was the designated adult safeguarding lead for the emergency department, and a senior paediatric consultant was the designated lead for children’s safeguarding in the emergency department. The safeguarding leads for the emergency department liaised with the designated safeguarding lead for the trust. Child protection nursing staff also worked within the department. A paediatric liaison nurse provided a link within the wider hospital for child safeguarding matters within the emergency department. Medical and nursing staff we spoke with said they felt safeguarding procedures in the emergency department were robust, and this had been strengthened by the introduction of the electronic patient record. Staff demonstrated they were conversant with safeguarding procedures in the emergency department. Staff were able to provide examples of actions they had taken in response to patients with safeguarding concerns. We asked staff to provide more details of investigations undertaken in response to specific incidents of concern which had occurred in the previous six months. We found that appropriate action was taken following the investigations and learning was shared within the emergency department and more widely in the trust. Safety alerts provided pertinent learning points for staff, for instance, missed safeguarding related to long bone fractures in toddlers, and missed shoulder fractures in adolescents were examples we reviewed. Safety alerts included “Top tips” and how to obtain further information. The outcomes of investigations were discussed at departmental and trust governance meetings. Staff were made aware through safeguarding training of child sexual exploitation, female genital mutilation (FGM) and adults and children at risk of radicalisation. Staff we spoke with told us that there was a non-mobile child policy which had been in place for a year. The policy related to children aged less than 12 months who attended the emergency department with burns, bruises, lumps or swellings. The children were immediately referred to the paediatric emergency department and a safeguarding referral was made. Staff we spoke with could explain the safeguarding referral system and gave an example of a referral they had made in relation to a child with non- accidental burns to their feet. Another example given was a safeguarding referral made because a patient admitted with a drugs overdose had children in their care.

Cleanliness, infection control and hygiene

Cleanliness audit monthly results (% compliance) for the emergency department in 2017 were: MONTH August September October November December Hand hygiene 93.02 100.00 100.00 94.67 96.23 Dress Code and 98.33 93.10 PPE (Bi-Monthly)

The trust provided mandatory training figures current at the time of our inspection. The overall 20171116 900885 Post-inspection Evidence appendix template v3 Page 36 completion rate of infection control training for the emergency department as at 10 January 2018 was 65.38%, as against the 47% completion rate reported for April 2016 to March 2017. Although this represented a significant improvement, it compared with a trust target of 95%. We observed that the emergency department was consistently cleaned to a high standard. The sluice area was clean although some little used equipment (commodes) was dusty. Hand washing facilities and alcohol gel were readily available. Labels were used for equipment to identify when items had been cleaned and were ready for use. Personal protective equipment including gloves and aprons was readily accessible in each separate area of the emergency department. We observed that medical and nursing staff used personal protective equipment when completing clinical tasks and they complied with bare below the elbow policy. We also observed that staff washed their hands and used hand gel when they left or entered the emergency department. Patients we spoke with in the emergency department also confirmed the high standard of cleanliness of the area they were using and that staff washed their hands when they arrived to examine them. Staff we spoke with told us that both the domestic and nursing staff had responsibility for ensuring the cleanliness in the department. We reviewed the records maintained by nursing staff which outlined their responsibilities for cleanliness and infection control which when completed were approved by the matron. The matron undertook a daily walk round the department to confirm the general cleanliness. During our inspection this was observed, however, the matron did not record that their observation had been completed or whether any concerns were identified. Staff we spoke with told us a range of infection control and hygiene audits were carried out on a regular basis. The hand hygiene audit was carried out monthly. A dress code audit was also carried out monthly by a nominated lead member of staff. The audit ensured compliance with the trust policy in relation to length of hair, length of nails, wearing of ties, bare below elbow and appropriate clothing. The department carried out a bi-monthly audit of the insertion of peripheral cannulas. The most recent audit results, for November 2017, showed the level of compliance was 83.33%. We were informed that the emergency department undertook an audit of the insertion of urinary catheters and of the decontamination of blood pressure cuffs, although we did not review the results of these audits. The findings were reviewed by the matron and a record made of the audit findings. The quality assurance check by the matron allowed either individual or team feedback with associated remedial training if required. Staff we spoke with told us that every six months the matron accompanied by an infection control nurse, a member of estates staff and a domestic supervisor undertook a check throughout the emergency department to check that trust policies and procedures were being adhered to, to observe the level of general cleanliness was acceptable and to identify where any remedial work to the environment was required to reduce infection risk. The infection control nurse assigned to the emergency department also undertook unannounced “spot checks” and audit findings were recorded. Audit findings were discussed with staff in the emergency department, at the divisional infection control meeting and at the clinical governance group meeting. Environment and equipment At our previous inspection in 2016 we identified concerns with the use of the public address system in the emergency department. We said the trust should review use of the public address

20171116 900885 Post-inspection Evidence appendix template v3 Page 37 system in the emergency department to ensure that patients were aware that they were being called and where they should go. We also identified concerns with the signage within the hospital grounds. We said the trust should review the signage to the emergency department within the hospital grounds to ensure that the department was clearly signposted.

At this inspection we found that a new emergency department had been opened since our last inspection in 2016 which addressed our concerns. The public address system was used appropriately and signs to the department in the hospital grounds were clear, although we had some concerns about the clarity of signs to the emergency department within the main hospital building.

A reception area for mobile patients was adjoined by a waiting area for adults with adjacent toilet facilities and a separate police office opening directly onto the waiting area. The waiting areas were visible from reception. The ambulance reception area was separate and four cubicles were provided with curtains, and used for ambulance triage, which was open 24 hours per day.

A paediatric waiting area was provided within a new, separate paediatric emergency department where children were directed to wait after arriving at reception and which was separate from the adults waiting area. The paediatric emergency department had eight cubicles and provided a dedicated environment for the care of paediatric patients. The paediatric area had four major cubicles and two high dependency cubicles.

The majors’ area consisted of 18 cubicles, two of which were fitted with doors and the remainder with curtains. We were informed that the two cubicles with doors were designed for the use of mental health patients, when accompanied by police or security staff. A third cubicle (cubicle four) adjacent to the central staff area was also used for the close observation of mental health patients.

Two rooms designated for the use of relatives were alarmed. The minor’s injuries unit consisted of five cubicles. The resuscitation area consisted of three bays. The emergency department was a designated trauma unit. When trauma facilities were required, one of the resuscitation bays was used for this purpose.

The high dependency unit (HDU) provided seven spaces for patients. The HDU was adjacent to the paediatric area and provided two bays which were equipped to provide resuscitation facilities. One of the HDU bays was equipped for paediatric resuscitation. The HDU also provided a step- down facility for patients from the resuscitation area.

A new clinical decision unit (CDU) was opened in November 2017 which provided 13 patient spaces. A side room in the CDU was available for the care and treatment of mental health patients when accompanied.

The ambulatory care unit (ACU) consisted of four trolley bays, 12 chairs, and six consulting rooms. The department did not have a designated room for the assessment of patients with mental ill health. However, patients were kept safe as alternative rooms were used in which equipment and furniture could be removed to reduce the risk of injury. Any ligature points were recorded in the department’s environmental risk assessment and security staff remained with patients at all times which mitigated any risk of self-harm or suicide by hanging. We observed that this took place in practice.

The local mental health trust was able to provide the use of a Section 136 suite at one of its nearby in-patient hospitals. A Section 136 suite is a facility for people who are detained by the police under Section 136 of the Mental Health Act. It provides a ‘place of safety’ whilst potential mental health needs are assessed under the Mental Health Act and any necessary arrangements made for on-going care.

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We found some concerns with the facilities in the reception area which were identified to us by staff who worked in this area. A barrier rail was attached to the front of the reception desk which had been provided to protect staff, but staff expressed concerns as to how this worked in practice.

A panic alarm system was available for reception staff to use in an emergency and this was in working order. Staff we spoke with told us that a business case for the installation of a screen to provide additional protection for staff had been submitted. On arrival in reception, patients were met with a sign instructing them to stop and wait to be called, which staff explained was to maintain confidentiality for patients already speaking with staff at the reception desk. We observed that some patients were confused by this, so that the instruction was not consistently followed.

We observed that no wheelchairs were available in the reception area and signposting, for example to the toilet facilities, was poor. No television or magazines were provided in the waiting area.

A primary care streaming service (co-located GP unit) was located next door to the emergency department. Patients were usually accompanied from the emergency department reception, although signage to the GP unit was poor.

We checked the equipment in each area of the department, including majors, resuscitation and paediatrics, the ambulatory care unit and the clinical decision unit. We observed the equipment was clean, well organised and fit for purpose. Each area of the emergency department maintained a store room which carried sufficient stock to replace used equipment.

Records we reviewed showed that checks of equipment were undertaken and reusable equipment was in place. Each item of equipment carried on trolleys was in date and associated electrical equipment had been portable appliance tested with stickers which identified when the next check was due.

All emergency trolleys followed a standard design for the trust. We reviewed the equipment check list of three emergency trolleys located in the emergency department. Each trolley was sealed and had been checked on the day of our inspection. The departmental process required daily checking including breaking the seal and signing in a trust standardised book that all the equipment was present and within expiry date. We reviewed check lists from 1 January 2018 and found that apart from on one day in each instance, checks were undertaken consistently and no other faults or defects were found. We also checked the emergency trolley in the ambulatory care unit (ACU) and found it had been checked on the day of our inspection and on each day in January.

We observed a member of staff as they checked and reviewed the in-date information of the equipment in a paediatric transfer bag. Staff told us this was done once a month or immediately after use. Once the check was completed the bag was tagged with the date the contents had last been checked.

Staff we spoke with told us the emergency department had 10 bariatric trolleys for the use with larger patients. We checked one of the trolleys and found it was in full working order. Staff told us an agreement was in place with a local supplier of beds and hoists so that if the department received notification that a patient was due to arrive in the emergency department weighing more than 200 kilograms, appropriate equipment could be supplied within one hour of the request. Staff confirmed this arrangement had been used on two occasions and equipment had been installed within the hour to enable the patient to be admitted into the emergency department.

Assessing and responding to patient risk Emergency Department Survey 2016 The trust scored “better than” other trusts for none of the five Emergency Department Survey

20171116 900885 Post-inspection Evidence appendix template v3 Page 39 questions relevant to safety. The trust scored “worse than” other trusts for three questions and “about the same” as other trusts for the remaining two questions.

Question Score RAG Q5. Once you arrived at the hospital, how long did you wait 8.2 About the same as with the ambulance crew before your care was handed over to other trusts the emergency department staff? Q8. How long did you wait before you first spoke to a nurse or 5.0 Worse than other doctor? trusts Q9. Sometimes, people will first talk to a nurse or doctor and 5.3 Worse than other be examined later. From the time you arrived, how long did trusts you wait before being examined by a doctor or nurse? Q33. In your opinion, how clean was the emergency 8.2 About the same as department? other trusts Q34. While you were in the emergency department, did you 9.0 Worse than other feel threatened by other patients or visitors? trusts

(Source: Emergency Department Survey 01/09/2016 - 30/09/2016)

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 is no more than one hour. The trust met the standard for 10 months over the 12 month period from November 2016 to October 2017. However, there was a sharp decline in performance in the most recent two months, September and October 2017.

Ambulance – Time to treatment from November 2016 to October 2017 at Bradford Teaching Hospitals NHS Foundation Trust

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

Median time from arrival to initial assessment (emergency ambulance cases only) Only one month of data relating to the median time from arrival to initial assessment was available at the time of production of this report, related to October 2017.

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In October 2017 the median time to initial assessment was 37 minutes compared to the England average of 8 minutes. (Source: Source: NHS Digital - A&E quality indicators)

Percentage of ambulance journeys with turnaround times over 30 minutes for this trust Bradford Royal Infirmary From December 2016 to November 2017 there was a slight upward trend in the monthly percentage of ambulance journeys with turnaround times over 30 minutes at Bradford Royal Infirmary, with some mild fluctuation from month to month. Overall, the trust averaged 45.6% of ambulance journeys a month with a turnaround time of 30 minutes.

Ambulance: Number of journeys with turnaround times over 30 minutes - Bradford Royal Infirmary

Ambulance: Percentage of journeys with turnaround times over 30 minutes - Bradford Royal Infirmary

(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 October 2016 to September 2017 the trust reported 269 “black breaches”, with a downward trend from October 2016 to February 2017, although there is a noticeable spike in September 2017. This may indicate the beginnings of an upward trend over the coming winter months.

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(Source: Routine Provider Information Request (RPIR) AC11 – Black Breaches)

Patients arriving at reception were clinically streamed by a qualified nurse, from 12 noon to 12 midnight. We observed that a qualified nurse was present with reception staff and listened to patients who arrived at reception. The nurse asked the patient some key questions and the patient was then streamed to other areas of the emergency department, which may include the co-located GP service, the minor injuries unit or the triage area. We saw that the streaming oversight role was undertaken appropriately. Patients could be directed from reception to the minor injuries unit or staff accompanied the patient to the co-located primary care assessment service. We reviewed the records for 53 patients which confirmed that in each instance, the patients received their initial assessment within 15 minutes of arrival.

The minor injuries unit formed part of the emergency department and patients may be streamed directly to the unit. A qualified nurse in the minor injuries unit also screened patients arriving and streamed patients to other areas of the department. The minor injuries unit was open from 8am to 12 midnight. It was usually staffed by an emergency nurse practitioner (ENP) and a clinical support worker. From midday an extra triage nurse was placed within the unit and patients were streamed directly to the unit from reception. Medical staff rotated into the unit when there was no ENP on duty or the unit was busy. We observed an ENP undertake the ‘see and treat’ of two patients: all aspects of the clinical care appeared safe and appropriate.

A standard operating procedure was in place for initial assessment which was displayed in the triage room. The nurse undertaking the initial assessment applied criteria for patients to be seen early and could also send patients home following triage. Investigations including for example ECG’s and bloods were initiated at triage. A senior doctor might also join the triage of patients, particularly at busy periods.

We found there was often an emergency consultant supporting triage, which had a positive impact on patient flow and experience as early clinical decisions could be made.

In the ambulatory care assessment unit, a series of “hot clinics” for specific specialties were held throughout the week, which included: stroke; respiratory; neuro medicine; gastro; renal; and infectious diseases. The unit also held a hot clinic to reassess patients to avoid admission. Accompanied children arriving at reception were accompanied to the adjoining, but separate paediatric emergency department. Paediatric patients also arrived by ambulance. We observed that an unwell child that arrived by ambulance was triaged immediately and a full set of vital sign checks were completed within four minutes. The observations were repeated after 10 minutes in line with trust policy. An advanced nurse practitioner was involved in the child’s assessment. We were informed that if concerns were identified, the paediatric department was contacted and responded promptly.

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For ambulance arrivals, ambulatory triage took place 24 hours per day seven days a week by an experienced registered nurse. Investigations were carried out at this point to aid patient flow. At the time of our observation there were two registered nurses and one support worker performing this role. We were informed the triage process was also supported by an emergency consultant. In one instance we observed that an ambulance crew waited more than 30 minutes to hand over a patient.

The triage was performed using a software tool which followed recognised triage guidelines. We observed the triage of three patients and in each instance a full set of vital signs were recorded; an early warning score was recorded and a clinical risk assessment was completed. Patients were offered support where appropriate, for example, pain scores were acted on and recorded.

The co-located GP service operated from 12 noon to midnight. We observed that patients directed to the primary care assessment area were accompanied there by reception staff. We spoke with the GP undertaking primary care assessment and streaming. They explained they no longer undertook investigations of patient’s conditions following assessment, but may refer the patient directly to acute specialties. We were informed that very few patients were sent back to the main emergency department.

We reviewed the records for 53 patients which confirmed that in each instance, appropriate early warning tools and pain scores had been used to manage patient risk. The early warning score was included in the electronic patient record. Staff we spoke with explained that when inputting patient information the early warning score included an alert if the score was high. The escalation procedure was to move the patient to majors or the high dependency unit.

A board round of patients in the department was undertaken regularly, usually every two hours, during the day and evening shifts by medical and nursing staff. We observed the board round undertaken on four occasions. The plan of care for each patient in the department was discussed. Patient risk was also reviewed at medical and nursing handovers. Consultants led the medical handovers and were represented at the nursing handovers.

Data from the 2016-17 Royal College of Emergency Medicine audit of severe sepsis and septic shock audit showed the trust was in the lower UK quartile for antibiotics administered within one hour of arrival. The trust achieved only 16% against a national average of 44%.

Medical and nursing staff we spoke with explained how patients at risk of sepsis were assessed and initiatives which had been introduced to improve the trust’s performance. Significant work had been undertaken to address sepsis performance including training and an awareness campaign. Sepsis trolleys had been introduced and the sepsis guidelines for adults and children had been reviewed. An emergency department consultant acted as sepsis champion and had introduced sepsis simulation to support training. The paediatric emergency department had introduced a standard operating procedure for non-mobile children and implemented new pathways for adults and children for sepsis. The emergency department were participants in the sepsis improvement group. Sepsis outcomes for the department were due to be re-audited in February 2018.

Screening for sepsis was included in the assessment and was flagged up by an early warning score of six or above. Initiatives recently introduced to support the identification and response for patients with sepsis included a sepsis champion and a sepsis trolley. Staff we spoke with were able to explain the paediatric sepsis pathway. The electronic patient record flagged if a patient was suspected with sepsis from the patient information entered on the system so appropriate action could be taken.

Staff we spoke with were able to explain the escalation procedures for deteriorating patients. We observed as staff implemented escalation procedures for several patients whose condition had deteriorated and who required immediate treatment. We observed evidence of rapid assessment and treat processes including two infants being transferred immediately to the paediatric unit,

20171116 900885 Post-inspection Evidence appendix template v3 Page 43 three patients being taken immediately to the resuscitation room and a patient being transferred immediately to the intensive care unit.

The clinical emergency medicine application for mobile devices recently implemented in the emergency department included an escalation module. Issues identified for escalation were escalated to key staff members to enable them to respond quickly to mitigate identified risks to patients.

Staff we spoke with explained that they examined patients when they were admitted for signs of pressure areas that could develop into a pressure sore. This allowed staff to take preventative steps and to share the information with the receiving ward if the patient was being admitted. Staff we spoke with told us the emergency department had recently won an internal award for the most pressure areas identified in a month.

Staff we spoke with told us that patients with a fall risk were identified during the triage process and a falls prevention plan was devised if the patient was as risk of a fall. Staff told us there had been two patient falls in the emergency department in the previous 12 months.

Staff told us that venous thromboembolism data was not collected in the emergency department because patients were not in the department long enough. Catheter associated urinary tract infection data was not collected in the emergency department. Staff told us that a catheter was only used if the patient was acutely unwell or acutely retentive. Audit activity was carried out on the wards in the hospital and if there were any identified concerns in relation to a catheter inserted by the emergency department the matron was informed.

Risk assessments for patients with ill mental health were undertaken by the local mental health trust’s psychiatric liaison team which was based within the emergency department. The mental health trust used its own risk assessment tool, which considered the patient’s history, potential to harm themselves and others, risk of harm from others, accidents and other risk behaviours and factors affecting risk.

We looked at risk assessments for 11 patients. Each risk assessment was up to date and we saw evidence that risk assessments were reviewed regularly. The care records also contained crisis plans for each patient which gave advice about what should be done if a patient was experiencing a mental health crisis.

The mental health trust provided Bradford Royal Infirmary with psychiatric support 24 hours a day, seven days a week. The onsite psychiatric liaison team operated between 7am and 9pm and the mental health trust’s first response team provided out of hours support.

When trauma facilities were required, one of the resuscitation bays was used for this purpose. We did not observe a patient admitted to the trauma unit during the inspection.

Nurse staffing The trust reported the following registered nursing staff numbers for urgent and emergency care as at September 2017:

Ward/Site Planned staff (WTE) Number in post (WTE) Bradford Royal Infirmary 93 75

(Source: Routine Provider Information Request (RPIR) – P16 Total numbers – Planned vs actual tab)

The following nurse staffing information is routinely requested within the universal provider information request spreadsheets, to be completed within a standard template. All staff were 20171116 900885 Post-inspection Evidence appendix template v3 Page 44 based at Bradford Royal Infirmary.

Vacancy rates

Bradford Royal Infirmary

From October 2016 to September 2017, Bradford Royal Infirmary reported a nursing staff vacancy rate of 11% in urgent and emergency care. The trust set no target for this standard.

(Source: Routine Provider Information Request (RPIR) P17 Vacancies)

Turnover rates

Bradford Royal Infirmary

From October 2016 to September 2017, Bradford Royal Infirmary reported a nursing staff turnover rate of 19% in urgent and emergency care. The trust set no target for this standard.

(Source: Routine Provider Information Request (RPIR) P18 Turnover)

Sickness rates

Bradford Royal Infirmary

From October 2016 to September 2017, Bradford Royal Infirmary reported a nursing staff sickness rate of 5% in urgent and emergency care. This is slightly higher than the trusts target figure of 4%.

(Source: Routine Provider Information Request (RPIR) P19 Sickness)

Bank and agency staff usage

Bradford Royal Infirmary

We have been unable to calculate bank and agency usage as a proportion of the total number of shifts available including those covered by permanent staff due to the fact that the total number of bank and agency shifts reported by the trust was often higher than the total number of available shifts.

From October 2016 to September 2017, Bradford Royal Infirmary reported bank usage for registered nurses in urgent and emergency care of 1,253 shifts and agency usage of 595 shifts. There were 776 shifts that were unfilled by bank and agency staff.

(Source: Routine Provider Information Request (RPIR) P20 Nursing – Bank and Agency)

At our previous inspection in 2016 we found that there were significant nurse staffing shortages in urgent and emergency services. We issued a requirement notice for the trust to ensure that at all times there were sufficient numbers of suitably skilled, qualified and experienced staff in line with best practice and national guidance, taking into account patients’ dependency levels. At this inspection we found that the previous shortages of nursing staff had largely been addressed. Our observation of the department and recent staff rota information submitted by the trust confirmed this.

The department rostered for full staffing and moved staff around the department depending on acuity. The rotas were planned to ensure an appropriate skill mix and was in line with the Royal College of Emergency Medicine guidelines. We reviewed a sample of the rotas and we were

20171116 900885 Post-inspection Evidence appendix template v3 Page 45 assured that staffing was well planned and at safe levels. No member of medical or nursing staff we spoke with felt that staffing was unsafe or a risk to patient safety.

On the first day of our inspection we observed the department was one qualified member of staff short; on the second day the department was fully staffed. Staff explained that the department planned for a more experienced nurse to supervise a less experienced staff member. The nursing shift leader reviewed the staff skill mix each day to ensure this. We observed the nursing handover which took place four times daily and which included allocating staff to areas of the department according to demand and availability of staff.

We observed that the paediatric emergency department was appropriately staffed for the level of activity. For the early shift, one registered nurse was supported by a clinical support worker; for the late shift, two registered nurses were supported by a clinical support worker or a third registered nurse; for the night shift, two registered nurses were supported by a clinical support worker. The rota reflected and staff confirmed that at least one paediatric trained nurse was always on duty in the paediatric department. This meant that the Intercollegiate Emergency Standard to have sufficient RSCNs to provide one per shift was being met.

The trust provided health care assistant support for the co-located GP unit from 12 noon to 12 midnight.

In the clinical decision unit (CDU), staff we spoke with told us that there had been an increase in staffing when the CDU had opened because the workload had increased. Staffing had increased from 15 to 20 nurses. In the ambulatory care unit, two registered nurses worked from 7.30am to 8pm, supported by two health care assistants.

Staff told us that agency and bank staff were used regularly. On the day of our inspection, three agency staff were included in the rota. We were unable to confirm the overall usage of agency staff.

Medical staffing

The trust reported the following medical and dental staffing numbers in urgent and emergency care as at September 2017:

Ward/Site Planned staff (WTE) Number in post (WTE) Bradford Royal Infirmary 60 56

(Source: Routine Provider Information Request (RPIR) – P16 Total numbers – Planned vs actual tab)

The following medical staffing information is routinely requested within the universal provider information request spreadsheets, to be completed within a standard template. All staff were based at Bradford Royal Infirmary.

Vacancy rates

Bradford Royal Infirmary

From October 2016 to September 2017, Bradford Royal Infirmary reported a medical staff vacancy rate 16% of in urgent and emergency care. The trust set no target for this standard.

(Source: Routine Provider Information Request (RPIR) P17 Vacancies)

Turnover rates

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Bradford Royal Infirmary

From October 2016 to September 2017, Bradford Royal Infirmary reported an overall medical staff turnover rate of 11% in urgent and emergency care. The trust set no target for this standard.

(Source: Routine Provider Information Request (RPIR) P18 Turnover)

Sickness rates

Bradford Royal Infirmary

From October 2016 to September 2017, Bradford Royal Infirmary reported a medical staff sickness rate of 1% in urgent and emergency care. This was lower than the trust’s target sickness rate of 4%.

(Source: Routine Provider Information Request (RPIR) P19 Sickness)

Bank and locum staff usage

Bradford Royal Infirmary

We have been unable to calculate bank and locum usage as a proportion of the total number of shifts available including those covered by permanent staff due to the fact that the total number of bank and locum shifts reported by the trust was often higher than the total number of available shifts.

From October 2016 to September 2017, Bradford Royal Infirmary reported bank usage for medical staff in urgent and emergency care of 1,032 shifts and locum usage of 1,348 shifts. There were 593 shifts that were unfilled by bank and locum staff. All of these shifts were at Bradford Royal Infirmary.

(Source: Routine Provider Information Request (RPIR) P21 Medical Locums)

Staffing skill mix

In August 2017, the proportion of consultant staff reported to be working at the trust were higher than the England average and the proportion of junior (foundation year 1-2) staff was also higher.

Staffing skill mix for the 46 whole time equivalent staff working in Urgent and Emergency Care at Bradford Teaching Hospitals NHS Foundation Trust. This England Trust average Consultant 32% 28% Middle career^ 5% 14% Registrar group~ 37% 35% Junior* 26% 23%

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^ 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 confirmed that the department’s establishment was 14 whole time equivalent (WTE) consultants and 13.8 WTE consultants were in post. The middle grade establishment was 11 WTE and 8 WTE middle grade staff were in post. There were 18 WTE registrars in post and locum medical staff were used to provide cover at weekends. The department planned to increase the consultant establishment to 18 WTE. The medical staff rota for the six weeks prior to our inspection confirmed that sufficient medical staff were available to resource the emergency department.

The emergency department had in place three qualified emergency nurse practitioners and one in training, which were included in the medical staffing rota.

Medical staff in the paediatric emergency department included a paediatric consultant and two paediatric emergency practitioners. Medical staff we spoke with confirmed that the medical staff rota allowed for a minimum of two doctors in the paediatric emergency department most of the time.

The ambulatory care unit (ACU) had at least one consultant in the unit from 8am to 6pm. A second consultant was provided from 4pm and a junior doctor was available between 10am and 6pm. At the time of our inspection one nurse practitioner was in post and the department was recruiting to fill the establishment of 4.5 WTE. The unit was open Monday to Friday only due to nurse practitioner vacancies. The department planned to extend ACU opening to support the evening peak of admissions in the department.

Medical staff we spoke with told us internal bank and agency locum staff were used and the department mainly employed medical staff who were familiar with the department. Consultant staff we spoke with felt that staffing in the emergency department was stable.

Medical handovers were held every two hours and we observed a selection of these handovers. Patient risk areas were covered appropriately for incoming staff. We observed that the emergency department was well covered by medical staff.

Records At our previous inspection in 2016 we found that there were significant concerns about the confidentiality and storage of records in urgent and emergency services. We issued a requirement notice for the trust to ensure that patient information was held securely and patient confidentiality was maintained particularly in relation to information about victims of domestic abuse and the storage of property bags for deceased patients. At the previous inspection in 2016 we also identified gaps in records in urgent and emergency services.

At this inspection we found that the emergency department had implemented electronic patient records in September 2017 and our previous concerns as to the confidentiality of records had been addressed.

During the inspection we reviewed 53 patient records in the emergency department including three patient records in the ambulatory care unit. The records were electronic so there were no issues

20171116 900885 Post-inspection Evidence appendix template v3 Page 48 regarding the legibility of hand writing. The electronic records had been set up with drop down information boxes which prevented the member of staff inputting the missing patient information and prevented them moving on to the next section until all the required information in the previous section had been provided.

Staff we spoke with told us that the initial patient booking-in process had been a little slower than using paper handwritten records but the benefits of the electronic system was that no information which could identify patient risk would be missed.

Each of the records we reviewed included completed national early warning scores (NEWS), risk assessments, an indication of when nutrition and hydration was provided, completed safeguarding checklist, when medication was provided, pre-existing conditions such as mental ill health, learning disability and dementia, and where appropriate included pain scores. We saw evidence that every patient record reviewed included the time the patient arrived, the time the patient was triaged and the time the patient was seen by a doctor or consultant. The time of discharge or time of a move to another department in the hospital was also recorded.

The electronic patient record system could be remotely monitored. We observed members of staff as they reviewed patient records to identify any delays in either discharging or moving a patient that was waiting for admission and required a bed. Staff were observed escalating delay issues to supervisors. The electronic patient record system was audited by supervisory staff to ensure that patient records were not being inappropriately accessed by staff who were not directly involved in treating the patient.

We observed staff adding information to the patient records to confirm when records had been reviewed by staff not directly involved in that patients care and the reasons why. The trust’s electronic records system did not include information about patients with ill mental health. However, the local mental health trust’s psychiatric liaison team, which was based at Bradford Royal Infirmary, held records on patients with mental ill health although these records were not accessible by staff at Bradford Royal Infirmary. We looked at 11 of these care records which were in relation to patients admitted in December 2017 and January 2018. They included details of each patient’s initial assessment, diagnosis, mental capacity and details of their care and treatment.

We also saw evidence that reviews of the patient’s diagnosis and mental capacity were being undertaken. We asked staff if the lack of access to these records caused difficulties and they told us that advice from the mental health trust was easy to access and they could either call them or see the psychiatric liaison team in person at any time.

Medicines At our previous inspection in 2016 we found that there were significant concerns about the management and storage of medicines, and particularly the use of patient group directions, in urgent and emergency services. We issued a requirement notice for the trust to ensure that the use of patient group directions in the emergency department followed trust policy.

At this inspection we found that our concerns as to the management and storage of medicines in the emergency department had mainly been addressed. Medicines were stored securely and access was restricted to authorised staff. Controlled drugs were appropriately stored and managed, and balance checks were carried out regularly in accordance with the trust policy. We found a pad of blank prescriptions stored in the controlled drugs cupboard in the majors area. Staff were unable to provide records of this controlled stationery to monitor its use in accordance with national guidance.

We checked medicines and equipment for emergency use and found they were readily available; however staff had not carried out regular checks in majors and HDU to ensure these were fit for use in line with the trust policy.

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We checked the storage and monitoring of medicines requiring refrigeration and found this was not always carried out in accordance with trust policy and national guidance. For example, in minors temperatures had been recorded on 10 days in December 2017 which were over the recommended range for storing medicines and no action had been recorded on the monitoring document. In addition, temperatures had not been recorded at all on nine days in December 2017 in the HDU area. We raised these concerns with the matron who gave us assurances that the medicines in these fridges remained safe to use.

We reviewed the fridge temperature records between 1 and 11 January 2018. The records had been recorded in accordance with the trusts policy and procedure, the fridge was recorded as functioning within the correct temperatures on each day. We inspected the medicines fridge in the ambulatory care unit. We observed the fridge was operating within the correct temperatures. The fridge had been subject to a daily check by the senior nurse on duty and the check was recorded. In the ambulatory care unit we checked five oxygen cylinders which we found were in date, correctly stored and secured in the store room.

Patient group directions (PGDs) were available to facilitate timely access to medicines. PGDs are written instructions which allow specified healthcare professionals to supply or administer a particular medicine in the absence of a written prescription. These had recently been transferred onto the electronic prescribing system and a programme of training and competency assessments was underway to ensure staff could use them safely. Further work was required to embed the new system and to improve the governance arrangements for PGDs.

Incidents Never Events

Never events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. 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 2016 to October 2017, the trust reported no incidents classified as never events for urgent and emergency care.

(Source: NHS Improvement – STEIS (01/11/2016 - 31/10/2017))

Breakdown of serious incidents reported to STEIS

In accordance with the Serious Incident Framework 2015, the trust reported one serious incident (SI) in urgent and emergency care which met the reporting criteria set by NHS England from November 2016 to October 2017. This incident was recorded as a treatment delay meeting SI criteria.

(Source: NHS Improvement - STEIS (01/11/2016 - 31/10/2017))

The emergency department recorded reported incidents in an electronic system widely used in the NHS. Staff we spoke with were clear how to report incidents. Learning was shared in the shift handover book, by emails to individual staff or if more serious in a face to face meeting with a supervisor which was recorded in the member of staff’s appraisal. If there was wider learning to be shared this was included in the team meeting and in team training. When incidents were investigated, lessons were shared within the emergency department and the wider hospital so that there was the opportunity for learning.

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The number of clinical risk incidents reported each month with an analysis of the type of incidents was included in the matron’s report to the quality and safety meeting. For example, in October 2017, 104 incidents were reported, and in November 2017, 113 incidents were reported. The main risks identified were pressure ulcers as well as some violent or aggressive patients. We saw from the agenda for the emergency department clinical governance meeting in January 2018 that feedback from the deteriorating patient collaborative and a review of the incident involving treatment delay were to be discussed.

The clinical lead told us serious incidents were circulated and discussed and other reported incidents were included in a matron’s report. The lead gave an example of several near misses and incidents for deteriorating patients which were collated and discussed with the trust medical director. An emergency department consultant led the development of actions in response to this, which included attending the deteriorating patient collaborative, the introduction of two-hourly reviews for resuscitation and the high dependency unit, and in situ simulations for incidents. Learning was circulated and posted as appropriate.

Safety alerts provided pertinent learning points for staff, for example, missed long bone fractures in toddlers, and missed shoulder fractures in adolescents were examples we reviewed. Safety alerts included “Top tips.” The outcomes of investigations were discussed at departmental and trust governance meetings.

We reviewed several examples of how learning was disseminated including “lesson of the week” “responding and improving.” Staff we spoke with told us about the learning zone board which included lessons learned from different departments.

As an example of an identified incident staff described a missed fracture. In this incident it was not appropriate to speak to the patient, a clinical review was undertaken with appropriate consultants and the findings of this review was fed back to staff via the matrons at safety huddles. The findings from the review were then fed back to the patient’s family and all related information was reported to quality and safety.

We asked staff to comment on the reporting of missed fractures as three missed fracture incidents were reported in two months. Staff told us that the reporting of the incident was normally completed while the patient was still within the department, with the exception of the night shift. Staff stated they believed that all incidents were reported within 24 hours but stated that they were unable to comment on individual incidents without checking the records.

Mortality and morbidity meetings in the emergency department were included in the agenda of the quality and safety meeting. Staff we spoke with told us that for mortality outliers, the lead for each department examined the data for themes and investigated these in more depth. Themes were reported to the quality and safety meetings and were discussed at handovers.

The duty of candour is a regulatory duty that relates to openness and transparency and 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. Where duty of candour incidents have been identified staff told us that the trust immediately contacted the patient to offer an apology as well as requesting more information. Findings were fed back to the emergency team by email and repeated at handover for two weeks following the incident. Staff we spoke with had been trained in duty of candour and they were able to explain what it meant. Staff gave an example of duty of candour where a burn on a child had been missed and the parents were informed.

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 20171116 900885 Post-inspection Evidence appendix template v3 Page 51 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, nine falls with harm and two new catheter urinary tract infections from November 2016 to November 2017 within urgent and emergency care.

Prevalence rate (number of patients per 100 surveyed) of pressure ulcers at Bradford Teaching Hospitals NHS Foundation Trust

Total pressure ulcers (0)

Total falls (9)

Total CUTIs (2)

(Source: Safety thermometer - Safety Thermometer)

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Is the service effective? Evidence-based care and treatment The emergency department followed recognised evidence-based care and treatment guidelines which were based on National Institute for Health and Clinical Excellence (NICE) and Royal College of Emergency Medicine (RCEM) guidelines.

The emergency department had recently implemented a clinical effectiveness tool on mobile devices which included a rule book feature within the application which supported access to departmental guidance documents. The built-in governance structure provided evidence-based guidelines for most clinical conditions for junior medical staff to follow.

We observed as members of medical staff accessed clinical guidance on the trust intranet. Examples reviewed included: head injury guidelines; pathways for risk assessment and management of acute upper gastrointestinal bleeding; guidelines for care and treatment of patients with spontaneous onset of myocardial infarction with ST-segment elevation (STEMI); NICE pathway for diagnosing, monitoring and managing asthma in children, the quality standard for diagnosing and managing hip fracture in adults, and guidelines for the prompt diagnosis and management of sepsis. Guidelines could be scanned into the electronic patient record. We were informed that junior medical staff were taught how to use the guidelines at induction.

Nutrition and hydration Emergency Department Survey 2016

In the CQC emergency department survey, the trust scored 5.5 for the question “Were you able to get suitable food or drinks when you were in the emergency department?” This was worse than other trusts.

(Source: Emergency Department Survey 01/09/2016 - 30/09/2016)

We observed that refreshment were available in the reception waiting area. Patients we spoke with confirmed that they were offered food and drink, where this was appropriate. Staff also confirmed that patients were offered nutrition and hydration when they were in the department.

We also observed that volunteers were available to support patients with food and drink. For example, we observed that one elderly patient who appeared to be confused was provided with a hot drink which gave her reassurance and helped keep her calm.

We saw evidence in the patient records that nutrition and hydration when given was recorded. If it was not appropriate to provide nutrition or hydration due to ongoing patient assessment this was also recorded.

Pain relief Emergency Department Survey 2016 In the CQC emergency department survey, the trust scored 5.8 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 7.0 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.

Question – Effective Score RAG

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Q31. How many minutes after you requested pain 5.8 About the same as other trusts relief medication did it take before you got it? Q32. Do you think the hospital staff did everything 7.0 About the same as other trusts they could to help control your pain? Q35. Were you able to get suitable food or drinks 5.5 Worse than other trusts when you were in the emergency department?

(Source: Emergency Department Survey 01/09/2016 - 30/09/2016)

Staff completing the electronic patient record were prompted to complete pain relief information. We were informed that nursing staff undertaking the patient’s assessment were proactive in completing the pain relief information. We reviewed 50 patient records in the emergency department. In each record, where appropriate the patient pain score was recorded. We also found evidence that pain relief was administered promptly where appropriate after the patient had been reviewed by a doctor.

Patient outcomes RCEM Audit: Moderate and Acute Severe Asthma 2016/17

In the 2016/17 Moderate and Acute Severe Asthma report, the trust failed to meet any of the standards.

The trust was in the upper UK quartile for two standards:

 Standard 4 (fundamental): Add nebulised Ipratropium Bromide if there is a poor response to nebulised β2 agonist bronchodilator therapy. Trust: 88.6%; UK: 77%.

 Standard 5: If not already given before arrival to the ED, steroids should be given as soon as possible as follows: within 4 hours (moderate). Trust: 53.9%; UK: 28%.

The trust’s results for the remaining four standards were all between the upper and lower UK quartiles.

(Source: Royal College of Emergency Medicine)

RCEM Audit: Consultant sign-off 2016/17

In the 2016/17 Consultant sign-off audit, the trust failed to meet any of the standards.

The trust was in the upper UK quartile for one standard:

 Consultant reviewed – patients making an unscheduled return to the ED with the same condition within 72 hours of discharge. Trust: 42.5%; UK: 12.2%.

The trust’s results for the remaining three standards were all between the upper and lower UK quartiles.

(Source: Royal College of Emergency Medicine)

RCEM Audit: Severe sepsis and septic shock 2016/17

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In the 2016/17 Severe sepsis and septic shock audit, the trust was in the lower UK quartile for four standards:

 Standard 2: Review by a senior (ST4+ or equivalent) ED medic or involvement of Critical Care medic (including the outreach team or equivalent) before leaving the ED. Trust: 35%; UK: 64.6%.

 Standard 5: Blood cultures obtained within one hour of arrival. Trust: 23.7%; UK: 44.9%.

 Standard 6: Fluids – first intravenous crystalloid fluid bolus (up to 30 mL/Kg) given within one hour of arrival. Trust: 20.4%; UK: 43.2%.

 Standard 7: Antibiotics administered: within one hour of arrival. Trust: 16%; UK: 44.4%.

The trust’s results for the remaining four standards were all between the upper and lower UK quartiles.

(Source: Royal College of Emergency Medicine)

RCEM Audit: Vital signs in children 2015/16

In the 2015/16 Vital signs in children audit, the trust failed to meet any of the standards.

The trust was in the upper England quartile for one developmental standard:

 Standard 2 (developmental). Children with any recorded abnormal vital signs should have a further complete set of vital signs recorded in the notes within 60 minutes of the first set. Trust: 30.8%; England median: 4.4%.

The trust’s results for the remaining five standards were all between the upper and lower England quartiles.

(Source: Royal College of Emergency Medicine)

RCEM Audit: Procedural sedation in adults 2015/16

In the 2015/16 Procedural sedation in adults’ audit, the trust failed to meet any of the audit standards (which were all 100%).

The trust was in the upper England quartile for one fundamental standard:

 Standard 1 (fundamental): Patients undergoing procedural sedation in the ED should have documented evidence of pre-procedural assessment, including:  Standard 1a. ASA grading  Standard 1b. Prediction of difficulty in airway management  Standard 1c. Pre-procedural fasting status Trust: 50%; England: 7.6%.

The trust was in the lower England quartile for one developmental standard:

 Standard 2 (developmental): There should be documented evidence of the patient’s informed consent unless lack of mental capacity has been recorded. Trust: 10%; England: 51.8%.

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The trust’s results for the remaining five metrics were all between the upper and lower England quartiles.

(Source: Royal College of Emergency Medicine)

RCEM Audit: Venous thrombo-embolism (VTE) risk in lower limb immobilisation in plaster cast 2015/16

In the 2015/16 Venous thrombo-embolism (VTE) risk in lower limb immobilisation in plaster cast audit the trust failed to meet any of the audit standards (which were all 100%).

The trust was in the upper England quartile for one standard:

 Standard 2 (developmental): Evidence that a patient information leaflet outlining the risk and need to seek medical attention if they develop symptoms for VTE has been given to all patients with temporary lower limb immobilisation. Trust: 17%; England median: 2%.

The trust was in the lower England quartile for one standard:

 Standard 1 (fundamental): If a need for thromboprophylaxis is indicated, there should be written evidence of the patient receiving or being referred for treatment. Trust: 66.7%; England median: 100%.

(Source: Royal College of Emergency Medicine)

Unplanned re-attendance rate within 7 days

From November 2016 and October 2017, the trust’s unplanned re-attendance rate to A&E within seven days was worse than the national standard of 5% and generally better than the England average.

Unplanned re-attendance rate within 7 days - Bradford Teaching Hospitals NHS Foundation Trust

(Source: NHS Digital - A&E quality)

We spoke with the emergency department’s lead consultant for national and local audit. The emergency department participated in the national RCEM audits to enable its practice to be compared with other emergency departments. Information provided by the department identified that it audited a range of pathways including those used from the RCEM. Action plans were in place to improve areas in the audit that were not at the required level.

We reviewed the emergency department’s audit timetable for 2017. We saw that audit results and comparative information were circulated by email within the department so that staff were aware of trends and action needed in response to audit results. The department’s audit lead told us that

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Royal College of Emergency Medicine audit results were presented in quality and safety meetings. Junior medical staff undertook one audit and the audit cycle was completed by another member of junior staff. In 2017 there were 15 medical trainees involved in audits, which were due to be reported during 2018. Results of audit showed the department was mainly above the national average.

We reviewed the department’s audit report for the spontaneous pneumothorax in adults audit reported in July 2017. The report included recommendations to improve the care and treatment of patients with COPD and the action plan included a planned re-audit 12 months after the implementation of electronic patient records to measure improvement.

Staff we spoke with told us that significant work had been undertaken to address sepsis performance including training and an awareness campaign. The department had introduced some initiatives following poor sepsis audit results in 2017, where the department was in the bottom quartile nationally. Sepsis trolleys had been introduced although we were informed these were underutilised. The sepsis guidelines for adults and children had been reviewed and an emergency department consultant acted as sepsis champion and introduced sepsis simulation to support training.

The paediatric emergency department had introduced a standard operating procedure for non- mobile children and implemented new pathways for adults and children for sepsis. The emergency department were participants in the sepsis improvement group. The sepsis audit showed very low antibiotics administration but medical staff explained this may be due to interpretation of data. Sepsis outcomes for the department were due to be audited again in February 2018.

We discussed the increase in the unplanned re-attendance rate within 7 days with senior emergency medical staff. As the increase coincided with the implementation of electronic patient records in September 2017, the department planned to undertake an audit in 2018 to explore the reasons for the increase.

Competent staff Appraisal rates From October 2016 to September 2017, 77% of staff within urgent and emergency care had received an appraisal compared to a trust target of 100%. The trust also reported more nursing staff completing an appraisal than were eligible. This was likely to be a recording error. Appraisals Appraisals Appraisal Trust Target Staff group completed required rate Target met? Nursing & Midwifery registered 65 62 105% 100% Yes Add Prof Scientific & Technical 1 1 100% 100% Yes Additional Clinical Services 15 23 65% 100% No Admin & Clerical 8 28 29% 100% No Estates & Facilities 0 1 0% 100% No

(Source: Routine Provider Information Request (RPIR) P43 Appraisals)

Discussions with medical and nursing staff confirmed they received regular appraisals and staff development opportunities within the emergency department were consistently well received by staff. Consultant emergency medical staff we spoke with confirmed new staff received a local

20171116 900885 Post-inspection Evidence appendix template v3 Page 57 induction of two days when they joined the department and all medical staff received an annual appraisal.

Staff we spoke with told us the induction training they had received was very informative and compared well to other inductions they had received. Staff who were in training told us they were assigned mentors who worked with them on each shift. They spoke positively about the level of support they received. Qualified nursing staff working at reception confirmed they received triage training and that this was updated. Agency nursing staff received a vetting and barring check and an induction from the registered nurse on duty before they worked in the emergency department. A senior member of nursing staff was the department’s lead for professional practice and development, which was a part time role at the time of our inspection. The department was submitting a business case for the role to become a full-time position.

For induction, new members of staff were treated as extra to the rota for their first four weeks, after which they received additional support from matrons for a number of weeks in addition to their formal training. Training courses included intermediate life support and patient advice and liaison services (PALS) where appropriate. The practice lead was planning to introduce a development programme for qualified band 5 nursing staff.

For advanced life support, staff told us the department tried to ensure that band 7 staff were up to date with advanced life support training and that there were at least two band 6 or 7 staff assigned to a shift at any time.

The paediatric emergency lead consultant explained that paediatric acute illness management (AIM) training and European paediatric advanced life support (EPALS) training had been undertaken by paediatric nursing staff in the department, except for one new member of staff. Regular training in paediatric immediate life support (PILS) was supported within the department and was attended by all staff who worked in the paediatric emergency department.

The trust supported staff undergoing advanced nurse practitioner training including mentoring for members of staff during their training. An advanced nurse practitioner who had completed their training was due to commence teaching the advanced paediatric life support course for the department in March 2018.

Medical and nursing staff described the process of simulation-based training in which the service simulated events in situ in a ward environment. Performance in these simulations was filmed and reviewed to facilitate learning. Staff we spoke with said the recording highlighted strengths and weaknesses and significantly improved both contingency planning and performance. Posters were produced from simulations highlighting key findings and learning points. The simulations were conducted monthly where possible and staff were positive about the process.

The trauma lead for the emergency department commenced her role in December 2017. The trauma lead told us that all consultant emergency medical staff and registrars had received training in advanced trauma life support. A programme of trauma and resuscitation team skills was due to start in January 2018 to support training for nursing staff to meet the requirement for all nursing staff to be level one compliant during 2018.

Multidisciplinary working We found there was effective collaborative working both within the emergency department and externally. Medical and nursing staff worked well together. A commissioning agreement was in place with a neighbouring mental health trust to provide support for patients experiencing ill mental health within the department. Arrangements with the local NHS ambulance service also operated effectively. The ambulance service used a ‘red’ phone to pre-alert the department to the arrival of seriously unwell patients. The emergency department followed regional guidelines for trauma patients which involved working closely with the nearest trauma centre, located in Leeds.

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We observed services working together effectively in the clinical decision unit to support the care and treatment of a patient with ill mental health who was found wandering in the hospital. We observed that emergency department medical and nursing staff worked effectively with staff from the mental health trust, the council, social services and an independent mental health hospital to provide appropriate care and treatment for the patient.

We also observed and spoke with independent ambulance staff who provided patient transport services as they liaised with nursing and support staff to support the effective discharge of patients from the department. If no one was available to receive the patient, the independent ambulance service would return the patient to the hospital.

The co-located GP service provided a significant level of resource to support the department, including out of hours services. Consultants we spoke with identified the need to develop further the links with primary care services in the Bradford area to support the use of joint patient pathways and to avoid unnecessary referrals to the emergency department.

Seven-day services The emergency department was open 24 hours a day, seven days a week. The ambulatory care unit was open from 7.30am to 8pm. Medical consultants and nursing staff worked on the unit from 8am to 9pm. Junior medical staff worked from 10am to 6pm. At the time of our inspection the ambulatory care unit was open from Monday to Friday only due to nurse practitioner vacancies.

Health Promotion

Staff we spoke with were aware of the above average level of deprivation and the below average life expectancy of people in the Bradford area. Patients who needed extra support were identified at their initial assessment and we observed a number of examples of specific support needs in the records we reviewed.

Patients were involved in regular monitoring of their health where this was appropriate to their needs. Specific examples we found included patients referred to the collocated GP service. Following discharge, patients were supported to manage their own health, care and wellbeing and to maximise their independence initially through referral to primary care services.

Procedures were in place to identify patients that required extra support. Agencies worked together to provide care and treatment services which were appropriate for the patient’s needs. Where abnormalities or other risk factors that required additional support or intervention were identified, changes to patients’ care or treatment needs were followed up as appropriate. For example, staff we spoke with told us the local mental health trust employed an alcohol key worker.

The key worker spoke directly with patients who were alcohol dependant to offer support and to direct them to support services. We found evidence in the patient records we reviewed that staff in the emergency department had access to the substance misuse liaison team and had made referrals.

Staff we spoke with also told us that patients may be signposted to local services operated by primary care which specialised in supporting patients with addiction. A homeless team was available to signpost patients that were homeless to a range of support services.

Staff we spoke with told us about the “Bradford dog bite board” which included representation from the council and the police. The board reviewed paediatric and adult patients who had attended the emergency department with a dog bite. The department operated an agreement to contact the police immediately to check whether the dog was dangerous and could present a risk to the public.

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During our inspection we did not observe examples of materials supporting health promotion in areas which were accessible to patients. For example, information about services for smoking cessation, obesity, drug and alcohol dependency, dementia or cancer prevention.

Consent, Mental Capacity Act and Deprivation of Liberty safeguards Mental Capacity Act and Deprivation of Liberty training completion The trust reported that from April 2016 to March 2017 Mental Capacity Act (MCA) training was completed by 97% of medical and dental staff and 99% of nursing staff within urgent and emergency care. The trust target was 95% completion. All staff were based at Bradford Royal Infirmary. The breakdown of course completion by staff group is shown below: Medical and Dental Staff Staff Completio Trust Target Course title Staff trained eligible n rate Target met? Mental Capacity Act Level 1 18 18 100% 95% Yes Mental Capacity Act Level 2 16 17 94% 95% No

Nursing and midwifery Staff Staff Completio Trust Target Course title Staff trained eligible n rate Target met? Mental Capacity Act Level 1 84 84 100% 95% Yes Mental Capacity Act Level 2 81 83 98% 95% Yes

(Source: Routine Provider Information Request (RPIR) P40 – Statutory and Mandatory Training) The trust had a policy covering the use of the Mental Capacity Act and Deprivation of Liberty Safeguards. Staff had an appropriate understanding of the Mental Capacity Act and Deprivation of Liberty Safeguards.

We saw evidence that consent, mental capacity and deprivation of liberty standards were recorded in patient records during initial assessment, at triage and when the patient was examined by a doctor, where appropriate. We reviewed evidence that appropriate action and support was provided for the patient that was flagged. We reviewed care records for 11 patients with ill mental health. Each of these records contained details of whether the patient had mental capacity.

The trust’s safeguarding team was responsible for the delivery of training in the Mental Capacity Act, which also included the use of Deprivation of Liberty Safeguards and making best interests decisions when patients lacked mental capacity. We looked at the course content, which was well detailed and easy to understand. The training was delivered to all staff within the trust. The training was mandatory and was delivered every three years although refresher training was also delivered annually.

The safeguarding team was also responsible for checking that Deprivation of Liberty Safeguards applications were correct. We reviewed five applications and noted where the safeguarding team had identified errors, which evidenced that quality assurance measures were effective.

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We were shown a pen that was issued to all staff. Each time the pen was clicked, the pen displayed one of the five principles of the Mental Capacity Act which meant staff were routinely reminded of what they should consider when considering if a person had mental capacity. Staff were able to seek advice about mental capacity, Deprivation of Liberty Safeguards and other issues related to mental health from the safeguarding team, the onsite psychiatric liaison and first response teams provided by the local mental health trust during out of hours.

Is the service caring?

Compassionate care Friends and Family test performance The trust’s urgent and emergency care Friends and Family Test performance (% recommended) was generally worse than the England average from November 2016 to October 2017. A&E Friends and Family Test Performance - Bradford Teaching Hospitals NHS Foundation Trust

(Source: NHS England Friends and Family Test)

At our previous inspection in 2016 we found that the privacy and dignity of patients was not adequately protected at all times. At this inspection we found that the emergency department’s move to new facilities had addressed our concerns and we were assured that the privacy and dignity of patients was maintained, except some concerns remained as to the layout of the reception area.

Patients we spoke with consistently gave positive feedback about their experience in the department. Patients we spoke with told us that staff were courteous and respectful and regularly checked with them about their comfort and wellbeing. Patients we spoke with said that staff treated them with kindness and compassion.

We observed staff interaction with patients and their relatives and carers. Staff were always polite, respectful and empathetic in their approach. Where patients were in some discomfort we observed staff responding compassionately to alleviate this in a way which was appropriate and timely. We observed that medical and nursing staff consistently provided compassionate care to patients and we observed that staff were very kind and compassionate with patients’ relatives too.

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We observed as staff in the ambulatory care unit assisted a patient to a chair. We observed that patient and compassionate care was delivered to support the patient, with appropriate moving and handling.

We observed that the confidentiality of patients may be compromised when they first arrived in the reception area and spoke with reception staff and the nurse undertaking streaming.

We spoke with senior medical staff as to their understanding of the sharp decline in the level of responses to the friends and family test during 2017 and particularly in September and October 2017. Staff explained that this coincided with the implementation of the electronic patient record. Staff were aware of the need to relaunch the friends and family test and at our inspection were planning the most effective way of achieving this.

Emotional support

In the contact with patients we observed, it was apparent that both medical and nursing staff understood the emotional impact of the patients’ care and treatment potentially had on the patient’s and their relative’s overall wellbeing.

We observed that staff provided appropriate and timely support to help them cope emotionally with their care and treatment. Patients were advised about how to access other support services and this advice was offered as early in the patient pathway as appropriate. Patients may be directed to other services from reception, where this was appropriate.

The emotional support provided by staff included the carers, family and dependants of patients attending the emergency department.

We also observed help and support being provided by a member of the volunteer service to an elderly patient who had been admitted alone and was confused.

Understanding and involvement of patients and those close to them Emergency Department Survey 2016 The results of the CQC Emergency Department Survey 2016 showed that the trust scored “worse than other trusts” in six of the 24 questions relevant to caring.

Question Trust 2016 2016 RAG Q10. Were you told how long you would have to wait to be 3.1 About the same as examined? other trusts Q12. Did you have enough time to discuss your health or 7.8 Worse than other medical problem with the doctor or nurse? trusts Q13. While you were in the emergency department, did a 7.7 About the same as doctor or nurse explain your condition and treatment in a way other trusts you could understand? Q14. Did the doctors and nurses listen to what you had to 8.5 About the same as say? other trusts

Q16. Did you have confidence and trust in the doctors and 8.4 About the same as

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Question Trust 2016 2016 RAG nurses examining and treating you? other trusts Q17. Did doctors or nurses talk to each other about you as if 8.7 About the same as you weren't there? other trusts Q18. If your family or someone else close to you wanted to 7.2 About the same as talk to a doctor, did they have enough opportunity to do so? other trusts Q19. While you were in the emergency department, how much 8.2 About the same as information about your condition or treatment was given to other trusts you? Q21. If you needed attention, were you able to get a member 7.0 Worse than other of medical or nursing staff to help you? trusts Q22. Sometimes in a hospital, a member of staff will say one 8.7 About the same as thing and another will say something quite different. Did this other trusts happen to you in the emergency department? Q23. Were you involved as much as you wanted to be in 7.5 About the same as decisions about your care and treatment? other trusts Q44. Overall, did you feel you were treated with respect and 8.2 Worse than other dignity while you were in the emergency department? trusts Q15. If you had any anxieties or fears about your condition or 6.5 About the same as treatment, did a doctor or nurse discuss them with you? other trusts Q24. If you were feeling distressed while you were in the 5.2 Worse than other emergency department, did a member of staff help to reassure trusts you? Q26. Did a member of staff explain why you needed these 8.1 About the same as test(s) in a way you could understand? other trusts Q27. Before you left the emergency department, did you get 7.7 About the same as the results of your tests? other trusts Q28. Did a member of staff explain the results of the tests in a 9.1 About the same as way you could understand? other trusts Q38. Did a member of staff explain the purpose of the 8.6 About the same as medications you were to take at home in a way you could other trusts understand? Q39. Did a member of staff tell you about medication side 4.4 About the same as effects to watch out for? other trusts Q40. Did a member of staff tell you when you could resume 5.1 About the same as your usual activities, such as when to go back to work or drive other trusts a car? Q41. Did hospital staff take your family or home situation into 3.6 Worse than other account when you were leaving the emergency department? trusts

Q42. Did a member of staff tell you about what danger signals 5.2 About the same as regarding your illness or treatment to watch for after you went other trusts

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Question Trust 2016 2016 RAG home? Q43. Did hospital staff tell you who to contact if you were 7.2 About the same as worried about your condition or treatment after you left the other trusts emergency department? 7.2 Worse than other Q45. Overall... (please circle a number) trusts

(Source: Emergency Department Survey 01/09/2016 - 30/09/2016)

Patients we spoke with told us that staff introduced themselves, communicated with patients and offered advice in a way that enabled the patient to understand their care and treatment. We observed staff as they explained to a mother who had accompanied an unwell infant as to what tests the emergency department were going to undertake and why. We also explained to an elderly patient and their partner that had been admitted with a stroke as to the next steps in their assessment and treatment.

Patients we spoke with confirmed that they felt involved in decision making and medical and nursing staff shared enough information to support their decision making. Patients’ carers, advocates and representatives including family members and friends were welcomed, and treated as partners in the delivery of their care. Staff ensured that patients, carers and their relatives were supported to obtain further information about their care and treatment. We observed that staff asked if what they said had been understood by the patient and if there were further questions the patients, relatives or carers had.

Staff sought accessible ways to communicate with patients which supported their equality and diversity and to access community and advocacy services, where appropriate. We observed staff seeking accessible ways to communicate with patients when English was not their first language by contacting language line. Patients were supported to use support networks and advocacy services. Staff routinely involved patients, carers and their relatives in shared decisions about their care and treatment.

Patients were assured that information about them was treated confidentially in a way that complies with the Data Protection Act and that staff supported patients to review choices about sharing their information.

Is the service responsive?

Service delivery to meet the needs of local people

At our previous inspection in 2016 we found the facilities and layout within the department was no longer sufficient or appropriate for the increasing demand on the service. Concerns were identified as to the lack of side rooms, the lack of a dedicated facility for mental health patients and limited access to isolation facilities. In addition the layout of the reception area did not protect the patient’s privacy and dignity.

At this inspection we found that the emergency department’s move to new facilities had addressed our concerns, except some concerns remained as to the layout of the reception area.

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Planning for service delivery was made in conjunction with commissioners and external providers to meet the needs of patients. For example, the emergency department worked with external partners to provide access to primary care services through a collocated GP service.

The facilities in the new emergency department designed to meet the needs of patients included a separate, dedicated paediatric emergency department. The high dependency unit (HDU) was adjacent to the paediatric area and provided two bays which were equipped to provide resuscitation facilities. One of the HDU bays was equipped for paediatric resuscitation. The HDU also provided a step-down facility for patients from the resuscitation area.

A new clinical decision unit (CDU) was opened in November 2017 which provided 13 patient spaces and a side room in the CDU was available for the care and treatment of mental health patients. The ambulatory care unit (ACU) consisted of four trolley bays, 12 chairs, and six consulting rooms.

The emergency department did not have a designated room for the assessment of patients with ill mental health. However, patients were kept safe as alternative rooms were used in which equipment and furniture could be removed to reduce the risk of injury.

Meeting people’s individual needs Emergency Department Survey 2016 The trust scored “about the same” as other trusts for all questions. Question – Responsive Score RAG Q7. Were you given enough privacy when discussing your 6.8 About the same as condition with the receptionist? other trusts Q11. Overall, how long did your visit to the emergency 7.0 About the same as department last? other trusts Q20. Were you given enough privacy when being examined or 8.9 About the same as treated? other trusts (Source: Emergency Department Survey 01/09/2016 - 30/09/2016) The emergency department addressed the information and communication needs of patients with a disability or sensory loss. The department recorded and shared relevant information with others when required, and gained patients’ consent to do so.

Emergency services were coordinated and made accessible to patients with different needs, including patients with protected characteristics under the Equality Act and those in vulnerable circumstances. Reasonable adjustments were made so that patients with a disability could access services on an equal basis to others.

Emergency services were delivered and co-ordinated to be accessible and responsive to patients with complex needs. Patients were supported during referral; transfer between services and at discharge. Senior medical and nursing staff in the department coordinated patients’ involvement with carers and relatives, particularly for patients with complex and long-term conditions.

Nursing and medical staff in the emergency department had access to a translation line and an interpreting service for patients where English was not their first language. The department had access to a sign language service. Staff we spoke with told us they used a text response system to support these patients. Nursing staff we spoke with in reception explained that interpreters were available within the hospital, and the emergency department could also access language line. We

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observed that advice literature in the emergency department was available in several languages other than English.

We saw evidence that further information about care and treatment was available through a range of information leaflets which were displayed in public areas. These leaflets were available in the emergency department for staff to hand to patients. However, there was no evidence that information leaflets included information about mental ill health, dementia or learning disability.

Staff we spoke with in the paediatric emergency department told us that they discussed with parents or carers the preferences of patients with a learning disability or with autism so that their care and treatment was appropriate to their needs. We observed during a board round that the needs of a patient with a learning disability were identified appropriately.

Flexible, responsive working relationships within teams and with external services meant the needs of patients with ill mental health were being met. We looked at the progress of one patient who came to the department with sepsis and affected pseudo aneurysm as a result of intravenous drug misuse being quickly assessed by the psychiatric liaison team who diagnosed them with severe psychosis. The patient was under the care of a local mental health hospital, and was admitted to a ward under section 3 of the Mental Health Act.

A senior member of nursing staff told us that they were able to make rooms available when the patient became distressed. Advice was also sought from a mental health nurse who worked in the trust’s safeguarding team about de-escalation techniques which included talking with them or playing music. An agreement between the trust and the local mental health trust was met so the patient could stay on the ward for a further three weeks due to concerns about their physical health. At our inspection, the patient was due to be discharged and admitted back to a local mental health hospital.

Access and flow 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 ED.

The trust breached the standard 12 times from December 2016 to November 2017.

From December 2016 to November 2017 performance against this metric has fluctuated but shown an overall trend of decline.

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Four hour target performance - Bradford Teaching Hospitals NHS Foundation Trust

(Source: NHS England - A&E Waiting times)

Percentage of patients waiting between four and 12 hours from the decision to admit until being admitted

From December 2016 to November 2017, Bradford Teaching Hospitals NHS Foundation Trust’s monthly percentage of patients waiting between four and 12 hours from the decision to admit until being admitted was better than the England average. Performance against this metric showed a trend of overall improvement, halving the number of patients from December 2016 to November 2017.

Percentage of patients waiting between four and 12 hours from the decision to admit until being admitted - Bradford Teaching Hospitals NHS Foundation Trust

(Source: NHS England - A&E Waiting times).

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Number of patients waiting more than 12 hours from the decision to admit until being admitted

Over the 12 months from December 2016 and November 2017, no patients waited more than 12 hours from the decision to admit until being admitted.

(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 November 2016 to March 2017 the monthly median percentage of patients leaving the trust’s urgent and emergency care services before being seen for treatment was similar to the England average. From March 2017 to October 2017 performance against this metric showed a trend of decline, deteriorating sharply from August to October 2017.

Percentage of patient that left the trust without being seen - Bradford Teaching Hospitals NHS Foundation Trust

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

Median total time in A&E per patient (all patients)

From November 2016 to October 2017 the trust’s monthly median total time in A&E for all patients was consistently higher than the England average. Performance against this metric showed a trend of decline.

The trust has shown a minor decline in May 2017, which it recovered from. In August 2017 there is a further trend of decline which has shown no signs of abating by the end of the reporting period.

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Median total time in A&E per patient - Bradford Teaching Hospitals NHS Foundation Trust

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

Arrival to assessment

At our previous inspection in 2016 we found that not all patients were being assessed within 15 minutes of arrival and the time spent in the department by patients was persistently higher than the national average. We said the trust should review the arrival to initial assessment times in the emergency department to ensure that patients were reviewed in a timely manner. At this inspection the time to assessment (average in minutes) was reported by the trust as:

2017 Apr May Jun Jul Aug Sep Oct Nov Dec mins 17 19 23 19 19 20 38 42 37

Ambulance arrivals

We reviewed the daily hospital situation report which showed the number of patients arriving by ambulance and ambulance handover delays between 20 November 2017 and 31 December 2017:

Month Patients Patients/day Delay 30-60 Delay/day Delay >60 Delay/day mins mins Nov 2017 1335 121 23 2.1 8 0.7 Dec 2017 3737 121 170 5.5 85 2.7

The emergency department reported no closures or diverts during this period.

Senior managers we spoke with confirmed that approximately 120 patients arrived by ambulance daily, which represented about 40% of the total numbers of patients who arrived at the department. The ambulance turnaround performance was reported to the department’s quality and safety meeting.

We observed the admission of six patients who arrived by ambulance and we saw that each patient was seen for assessment within 15 minutes of arrival. Ambulance crews we spoke with told us that there was always a doctor on duty in the emergency department so that patients were

20171116 900885 Post-inspection Evidence appendix template v3 Page 69 handed over and assessed quickly. However, we did observe that one ambulance crew waited more than 30 minutes to hand over the patient.

Streaming

We observed the streaming of patients from reception, and the triage of patients in the minors area and in ambulance arrivals. The streaming of patients was operated from 12 noon to 12 midnight daily. A qualified nurse supported the reception staff to send patients to the most appropriate destination within the department from the reception. We observed as two patients with minor injuries were sent to the minor injuries unit and a patient was sent direct to the paediatric unit. We observed that patients arriving took an average of five minutes at the reception. A full triage of the patient was undertaken after the streaming process was completed.

Before the inspection we received information which alleged that too much emphasis was placed on what the receptionist wrote down and not on the actual symptoms experienced by the patient. This was not confirmed by our observation of reception.

Triage

Triage of patients who arrived by ambulance was operated 24 hours a day by an experienced registered nurse. At the time of our observation we saw two registered nurses and one support worker performing this role. The triage was undertaken using recognised triage guidelines. We observed the triage of three patients and each received: a full range of vital sign checks; an early warning score; a clinical risk assessment; pain scores, and action taken in response; support offered as appropriate, each of which was recorded for each patient. A standard operating procedure for initial assessment was displayed in the triage room.

The triage process was also frequently supported by the emergency consultant working in resuscitation and the high dependency unit during the day. The presence of the consultant had a positive impact on patient flow and enhanced the patient experience as early clinical decisions could be made.

Before the inspection we received information which alleged that triage times and the quality of nursing experienced at the triage were poor. This was not confirmed by our observation of the triage process.

Investigations

Investigations such as electrocardiograms and blood tests were initiated at triage. Staff we spoke with told us blood results requested by the emergency department were returned within an hour, urea and electrolyte results were returned within two hours and blood cultures within 48 hours.

Waiting times in the department

We spoke to a selection of patients and people in the emergency department waiting room, to ask how long they had been waiting, whether they had been triaged, and to gain general impressions and comments.

Patients we observed waiting in the emergency department experienced waiting from just five minutes to three hours. Of the patients who had waited more than 20 minutes all except one told us that they had been seen and triaged. For 11 patients we observed, the average waiting time was 98 minutes. No patient we spoke with had waited on this occasion, or had any experience of waiting longer than four hours.

The average wait time of the patients we spoke with varied due to arrival times but no patient had waited more than three hours and one patient told us that three hours was the usual waiting time

20171116 900885 Post-inspection Evidence appendix template v3 Page 70 they had experienced. Patients we spoke with were generally happy with their experience in the department. Patients had no specific complaints and although most said they would like to be seen faster they understood the reasons for the delay and felt sufficiently updated. Our observation confirmed that waiting times were communicated to patients.

Before the inspection we received information which alleged that there was a lack of oversight of the waiting area with receptionists being left to observe unwell patients. This was not confirmed by our observation of the waiting area.

Patients we spoke with in the department following their triage said they were seen by a doctor or a nurse in a timely manner.

GP co-located primary care unit

We observed the collocated primary care streaming service and spoke with the GP undertaking the assessment of patients. The GP service operated from 12 noon to midnight during which four GP’s saw patients during a six hour shift. Each GP saw an average of 16 patients during their shift. We were informed that 20 to 25% of patients attending the department were seen for GP assessment and that no patients were deflected to primary care. The GP service did not conduct investigations, but could refer directly to specialities within the hospital. Very few patients were returned to the main emergency department.

Senior managers confirmed that the 135,000 patients seen by the emergency department annually included those seen by the collocated GP service.

Clinical decision unit

The clinical decision unit (CDU) had opened in November 2017 and provided 13 patient spaces for a maximum stay of 23 hours. We were informed that the longest stay to date had been 11 hours. A side room in the CDU was available for the care and treatment of mental health patients.

The unit was used for patients that were likely to be discharged from the hospital. We observed the functioning of the unit and saw that of three patients; two were ill mental health patients. One patient was in the side room awaiting the outcome of a multidisciplinary assessment. The patient transport service was collecting the third patient following discharge.

Ambulatory care unit

The ambulatory care unit (ACU) was consultant led and the consultant on duty received GP referrals from the community and from the collocated GP unit, and they assigned the patient to the appropriate pathway, which included the use of step down facilities prior to discharge. The unit saw approximately 35 patients daily which included 15-20 ‘new’ patients and 10-15 ‘returners.’

The ambulatory care unit operated during weekdays a series of hot clinics for specific specialties which included: stroke; respiratory; neuro medicine; gastro; renal; and infectious diseases. The unit also held a hot clinic to reassess patients to avoid admission.

Minor injuries unit

The minor injuries unit (MIU) was open from 8am to midnight and patients could be streamed to the MIU. An emergency nurse practitioner (ENP) was assisted by a clinical support worker. From midday a second triage nurse was placed within the unit and patients were streamed directly to the unit from reception. Medical staff rotated into the unit when there was no ENP on duty or the unit was particularly busy.

Paediatric emergency department

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The paediatric emergency department included a separate paediatric waiting area where children were directed to wait after arriving at reception and which was separate from the adults waiting area. We reviewed the patient record for an unwell child that arrived in the department by ambulance at 10:04 and was triaged immediately. A full set of vital signs was completed by 10:08 and observations were repeated 10 minutes later in line with trust policy. We identified no issues with this pathway.

Mental health assessment

We observed medical and nursing staff worked with staff from the local mental health trust to support the care and treatment of patients with ill mental health. We observed that a patient with a mental health diagnosis who had been in the department for 10 hours 19 minutes was awaiting further assessment. Staff confirmed that patients with ill mental health who were waiting for a further assessment could wait for eight to nine hours in the emergency department. Some patients waited to see the psychiatric liaison nurse and this could cause extended delays.

Emergency care standard

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 A&E. The four hour standard was not identified as an area of concern at the last inspection in 2016. However, the trust breached the standard continuously from December 2016 to November 2017 and in addition, from March 2017 the performance against the 4-hour standard has been below the England average.

Performance against the four hour standard for November 2017, December 2017 and for January 2018 up to and including our inspection was:

Month Actual attendances Contract attendance 4-hour 95% standard November 2017 13050 11088 84.97% December 2017 13477 11181 82.96% 1-14 January 2018 5851 4817 82.33%

Senior managers we spoke with about compliance with the four-hour standard explained that the implementation of electronic patient records from September 2017 had a substantial detrimental impact on the department’s achievement of the standard. We were assured by managers that as staff became more familiar with the electronic record system efficiency was improving and staff were embracing the change. Managers also stated that a lack of available mental health services and beds had delayed a number of patients requiring mental health treatment or assessment.

The emergency department’s risk register for January 2018 stated that non-compliance with the four-hour standard in the emergency department led to a poor patient experience, clinical risks of patients waiting to be seen, financial penalties and trust reputation. To address these risks, the department had in place an emergency care recovery programme plan linked to its hospital flow and discharge project.

Actions were coordinated and key performance information monitored with the stated aim of contributing to the achievement of the 95% emergency care standard by March, 2018. The recovery programme was linked to the achievement of the hospital’s winter plan. Within the emergency department a manager was present 24 hours to facilitate performance against the four-hour standard.

Patient flow in the hospital

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An acute assessment area and medical admissions unit located adjacent to the emergency department opened in August 2017. There was also a separate medical assessment area for elderly patients and a short stay unit with 14 bed places. We observed as a consultant from acute medicine in close liaison with medical staff in the emergency department assessed patients who were suitable to move to the AMU and ACU. The consultant identified six patients.

The ambulatory care unit operated during weekdays a series of hot clinics for specific specialties and also held a hot clinic to reassess patients to avoid admission which we were informed took 10 to 12 patients daily from the emergency department. The dialysis unit was also located adjacent to the emergency department and we observed that the adjacent departments worked closely with the emergency department to facilitate the flow of patients in the hospital.

We reviewed a report of the second year of operation of the emergency department’s musculoskeletal clinic which was a service for active or athletic patients who arrived in the department with large joint soft tissue injuries that would benefit from early follow up. The aim was to return patients to their previous functioning levels as soon as possible with physiotherapy, further investigation and referral to specialist services if required. Referrals were made through the emergency department reception but the patient reported to the physiotherapy department. The report demonstrated the clinic was an effective route to physiotherapy with short waiting times, supported by clear communication between the emergency department, physiotherapy and orthopaedics. There was a significant improvement in referral times from the emergency department to the clinic and from the clinic to obtaining a scan. Patient satisfaction was high.

The clinical emergency medicine application for mobile devices recently implemented in the emergency department as a reporting tool with action cards provided an online situation report linked to electronic action cards for operational medical and nursing staff and provided live updates. The application enabled key performance information to be shared by senior medical and nursing staff and supported staff members in responding quickly to mitigate identified risks to patients.

Patients leaving before being seen

The most recent performance data from the trust for patients left the department before being seen or who refused treatment was:

Month of Apr May Jun Jul Aug Sep Oct Nov Dec 2017 Left before 4.10 4.80 3.60 2.90 3.60 5.60 9.90 6.90 7.80 being seen % Refused 2.40 2.70 2.30 2.50 1.50 1.50 0.20 0.30 0.20 treatment %

We discussed with senior managers the sharp rise from August 2017 in the number of patients who left the department before been seen, and the decline in the number of patients who refused treatment for the same period. Following our inspection the emergency department planned to undertake an immediate audit to investigate the possible reasons for the trend.

Escalation

The trust had in place an escalation policy to enable it to respond appropriately in periods of particularly high demand. Within the emergency department, the escalation process was informed by the clinical emergency medicine application to determine the escalation status for the department.

Learning from complaints and concerns

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Summary of complaints From October 2016 to September 2017 there were 69 complaints about urgent and emergency care. The trust took an average of 51 working days to investigate and close complaints; this is not in line with their complaints policy, which states complaints should be resolved within 30 days of receipt. The most common cause of complaint was recorded as ‘aspects of clinical treatment’ with 44 complaints, staff attitude being the next most common with 11 complaints. (Source: Routine Provider Information Request (RPIR) P61 Complaints)

At the inspection the trust provided an update of its complaints information as follows: Complaints for A&E 1 April to 31 December 2017 Number of complaints received 39 Withdrawn complaints 2 Complaints responded to within 30 working days 16 Complaints responded out of time frame 9 Complaints currently under investigation 12

Senior medical and nursing staff told us they were proud to have reduced formal complaints by 50% and that the main informal complaints had involved trends of waiting times and insufficient communication causing difficulty in patients understanding their care.

Patients we spoke with said they felt comfortable in raising any concern and said they knew how to complain if necessary.

Staff we spoke with explained the complaints process including the investigation and feedback to staff and the complainant. Staff told us how they had investigated and reported the findings of a complaint to staff and how they had kept the complainant informed in accordance with trust policy.

Is the service well-led?

Leadership The clinical director within the medicine division had oversight of the emergency department, supported by the clinical lead and head of the department. The nurse manager and the lead matron for the emergency department worked in a management cluster to lead the operational management of the emergency department.

Medical and nursing staff spoke positively of the management arrangements in the department and of the clinical leadership. There was a strong positive relationship between managers and staff. Staff spoke highly of the matron, of the nursing leadership, and of the strong leadership they experienced working in the emergency department. Leaders were seen as reliably visible up to and including executive level. One member of staff told us the consultants were really helpful and the department was one of the best places they had worked.

We observed that leaders in the emergency department were visible. We observed the clinical leadership and strong nursing leadership functioning in the department and managers interacting, helping and supporting staff.

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The trust’s organisational development function had developed a series of “leadership essentials” workshops to support members of staff who were looking to develop their leadership skills. The workshops were open to all staff across the organisation, regardless of their current role. Workshops were scheduled until the end of March 2018.

Vision and strategy Managers told us the vision and strategy for the emergency department was linked to the “we are Bradford” vision for the trust. The department embraced the overall mission of the trust to provide the highest quality healthcare at all times. The mission supported the vision to be an outstanding provider of healthcare, research and education and a great place to work. The vision was supported by the strategic objectives of providing outstanding care for patients; delivering the financial plan and key performance standards; to be in the top 20% of NHS employers; to be a continually learning organisation, and, to collaborate effectively with local and regional partners.

Corporate and departmental values which supported the achievement of the vision and strategy were developed and embedded through workshops, “Bringing our values to life” to increase staff awareness of the mission, vision, strategic objectives and values.

The vision and strategy was supported by the clinical services strategy for 2017-2022. The emergency department directorate plan for 2018/19 to 2020/21 for the department, within the division of medicine and integrated care, included annual plans and key actions to achieve the vision.

Managers we spoke with confirmed the vision, strategy and the key priorities for the department matched those of the overall clinical strategy, in providing quality care and collaborative working. Research and evidence based care was also considered a key priority. Improving emergency care standards and ambulance turnaround times were also highlighted.

Culture An organisational culture work stream for the emergency department was linked with a wider organisational development work programme for the trust which included a plan of activities included timeout sessions which were used to develop and embed the positive culture of the department. A personal responsibility framework linked to the mission and values for the emergency department and the trust.

Medical and nursing staff we spoke with felt the culture of the department was still evolving following a significant level of engagement by management teams on improving internal and external communications. Staff we spoke with described the culture as putting patients first. Staff felt the culture was positive, friendly and open with high staff morale which was enhanced by genuine team work. Our observation of the department confirmed this. One member of staff told us that the moment they left the emergency department they knew they wanted to work there.

For the security of patients and staff, on site arrangements were in place with security and the police. We observed the internal security staff operating within the emergency department as well as other parts of the hospital in particular public areas with high footfall. They were highly visible and were observed interacting with members of the public. A small police office was located in the emergency department and opened directly into the reception waiting area. Staff we spoke with told us of several examples when police officers had intervened to deal with violent and abusive patients and visitors.

Governance

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The service was previously rated as ‘good’ for well led. During this inspection we confirmed that well-led at emergency department level was stable with elements of good practice.

We found there was an effective governance structure in place in the emergency department. There were appropriate governance processes and systems of accountability to support the delivery of the department’s strategy and to support the delivery of high quality, sustainable services. We saw evidence that the department’s processes and systems were reviewed through regular audit and monitored to support improvement.

The governance structures within the emergency department were supported through an effective management team at departmental level which linked well within the medicine division and the wider trust. We found that medical and nursing staff at all levels were clear about their roles so that they understand what they were accountable for within the emergency department, and who they reported to.

We saw evidence that the emergency department’s arrangements to link with partners and third- party providers were managed effectively and supported with appropriate governance arrangements. The department’s proactive approach to working with partners both promoted and provided assurance of the consistent delivery of coordinated, person-centred care and treatment for patients.

We reviewed the minutes of the emergency department’s quality and safety meeting for the most recent three months (October to December 2017) and the agenda for the January 2018 meeting. We found quality and safety was the main governance meeting for the emergency department. The meeting followed the format of CQC’s five key questions and the minutes showed that issues discussed included topics which were relevant to these questions, for example, incidents, infection prevention and control and NICE guidance. We saw from the minutes of meetings that quality and sustainability issues were included in governance meetings where this was relevant. Audit findings were presented to the meeting and outcomes and actions from the meeting were documented for follow up. Matters for escalation the divisional quality and safety meeting were identified.

A consultant in emergency medicine was the department’s lead for clinical governance. We were unable to interview the lead for clinical governance.

Management of risk, issues and performance We spoke with senior managers as to how performance against key targets for the emergency department was managed and monitored. Managers described how monthly directorate meetings took place with key leads in other services as well as separate meetings with clinical staff. At these monthly directorate meetings consultants, nurses, governance and quality control staff were all invited to attend.

The clinical governance structures within the emergency department supported through the management team provided assurance that systems were in place to manage and monitor performance. We saw that performance issues were escalated appropriately following appropriate departmental guidance. Plans were in place to manage both current and future performance, which were regularly reviewed. For example, the department had in place an emergency care recovery programme plan linked to its hospital flow and discharge project. Actions were coordinated and key performance information monitored with the stated aim of contributing to the achievement of the 95% emergency care standard by March, 2018.

The department’s lead for national and local audit was a consultant in emergency medicine. We reviewed the emergency department’s audit programme and timetable. The department followed a system of clinical audit for a range of pathways and operational situations within the department to monitor quality, including those used from the RCEM.

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We saw that action plans were in place for areas of improvement identified from audits. We saw that audit results and comparative information were circulated by email within the department so that staff were aware of trends and action needed in response to audit results. Audit results were presented in quality and safety meetings.

We reviewed the emergency department’s risk register as at 10 January 2018. This reflected current risks, including ambulance arrivals, delays for patients waiting and non-compliance with the four-hour standard, consultant weekend cover and the care and treatment of mental health patients in the department. The risk register included reference to poor patient experience, clinical risks for patients waiting to be seen, financial penalties and risks to the trust reputation and mitigation and action to be taken was recorded and monitored.

A consultant in emergency medicine was the department’s risk lead. Managers we spoke with told us how the service managed risk. Regular meetings for risk leads were held to discuss strategy, quality and safety. The matron worked with the risk leads to manage risk. There were monthly meetings to review outstanding incidents, which may then also be discussed at the quality and safety meetings and escalated further if necessary.

The minutes of the emergency department’s quality and safety meeting for October to December 2017 showed that the department’s risk and governance facilitator attended the meeting and the risk register was reviewed and updated monthly. For example, the electronic patient record implementation risks were reviewed following go-live, but the item was retained on the risk register because of ongoing enhanced risks. Risks for escalation to the divisional quality and safety meeting were identified.

The impact of potential risk was taken into account in service planning. We found evidence the emergency department had considered the impact on quality and sustainability in the design of the new emergency department within the constraints of the existing hospital site and buildings.

However, during a board round in which the care and treatment of a patient with ill mental health was discussed, we found that two consultants in emergency medicine present had an insufficient understanding of the concept of risk management. We discussed our concern with them during the inspection.

Information management Information was used to monitor and manage the operational performance of the department, and to measure improvement. Service performance measures were monitored and reported. Performance information presented to staff was mostly robust, although staff identified to us some items where they were less assured about the quality of data. Some key operational information was not presented as clearly as it might be, and we discussed these areas with managers during the first day of our inspection.

When we subsequently interviewed senior staff we were informed that screens located in the waiting area had been activated following our comments to keep patients informed of wait times. We observed that the current waiting time was displayed on the screen in the waiting area. The department planned to link these screens to the electronic patient record system to show wait times in all areas. A whiteboard had been provided in the minor injuries unit to displaying wait times. It was the responsibility of the nurse conducting streaming on the front desk to update the information.

Nursing and medical staff in the emergency department could access key operational information live. A new tracking system was implemented in the emergency department during 2017. We observed the dashboard with patients presented in clinical priority order and with status information including their length of stay in the department. The dashboard also included key 20171116 900885 Post-inspection Evidence appendix template v3 Page 77 operational information about the department, although this was not presented on the main tracking board. We observed several board rounds where the care and treatment of patients was reviewed using the latest, live information. We observed that both medical and nursing staff used the information presented to constructively challenge the basis of decisions made about patients’ care and treatment.

Information technology systems were used effectively. Both medical and nursing staff we spoke with told us that the implementation of the electronic patient record in the department in September 2017 had a directly positive impact in monitoring and improving the quality of care for patients.

The emergency department’s submission of data and notifications to external bodies was in place. For example, the system used to report incidents, recorded in an electronic system widely used in the NHS, was already well established and was not changed as a result of the implementation of electronic patient records.

The clinical emergency medicine application for mobile devices which was recently implemented in the department provided a reporting tool for key operational medical and nursing staff and provided an online situation report, an escalation module and links to electronic action cards which provided live updates. The application enabled key performance information and issues identified for escalation to be shared by senior medical and nursing staff.

We observed the nurse in charge and consultant in charge as they prepared an online situation report of the live state of the department. The clinical emergency medicine application required the consultant and nurse in charge to record the total patients in the department; the total attending in last hour; the capacity and waiting time for each area of the department: majors, paediatrics, HDU, Minors; medical and nurse staffing; and the number of patients waiting and beds. The application included a comments section. When data input was completed the application presented action cards for the consultant and senior nurse to follow. Outcomes were sent in real time to relevant staff across the trust.

We spoke with the emergency department consultant who recently became the lead for the trauma unit. The department had recently commenced the submission of data to the trauma audit and research network and was awaiting the report from an external peer review of the trauma unit which had taken place in November 2017.

We received assurance from senior managers as to the integrity of the emergency department’s data management systems compliance with data security standards. We observed that no information for patients was available in the reception area.

Engagement Friends and Family test performance The trust’s urgent and emergency care friends and family test performance (% recommended) was generally worse than the England average from November 2016 to October 2017.

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A&E Friends and Family Test Performance - Bradford Teaching Hospitals NHS Foundation Trust

(Source: NHS England Friends and Family Test)

The emergency department was aware of the very low response it achieved in the friends and family test. At reception we observed that no member of staff actively handed the friends and family card to the patient and no pens were available in the reception waiting area or given out to patients. Staff we spoke with told us that although cards were available sometimes, there were no pens.

We discussed with senior managers the deterioration in friends and family feedback rates within the last 12 months. We found the department was reviewing the way in which patients’ views and experiences were gathered. We were informed that work was in progress to improve the response rate and we saw evidence in minutes of meetings which confirmed this. We also found that patients we spoke with had received a feedback form. A new kiosk was planned at the exit of the department and volunteers were being used to seek feedback from patients.

Patients, and their carers, relatives and representatives were actively engaged in helping to shape services and were involved in decision making. Patients were represented in a range of groups reflecting equality and diversity which were consulted about emergency services.

Staff were actively engaged so that their views were reflected in the planning and delivery of services. Staff we spoke with told us that they had been consulted on and had been actively involved in the design of the new emergency department.

Emergency services and more widely the medicines directorate had developed collaborative relationships with external partners. Potential challenges within the healthcare system were addressed so that services were delivered to meet the needs of the local population.

We found there was effective collaborative working both within the emergency department and externally. The service worked with commissioners and an agreement was in place with a neighbouring mental health trust to provide support for patients experiencing ill mental health. Arrangements with the local NHS ambulance service operated effectively and services were commissioned from independent ambulance providers, for example patient transport services.

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Learning, continuous improvement and innovation The emergency department supported and encouraged an environment of continuous learning, improvement and innovation. Staff participated in appropriate research projects and recognised accreditation schemes. The department used both standard and innovative tools and methods to support the development of staff skills. We saw evidence that staff regularly took time out to work together to resolve problems and to review individual and team objectives, processes and performance. This approach supported improvements and innovation.

The emergency department’s musculoskeletal clinic was in its second year of operating. The clinic provided an early follow up for active or athletic patients who arrived in the department with large joint soft tissue injuries. The clinic aimed to return patients to their previous functioning levels as soon as possible with physiotherapy, further investigation and referral to specialist services if required. Referrals were made through the emergency department reception but the patient reported directly to the physiotherapy department. The clinic enabled patients to access physiotherapy services with short waiting times. Communication between the emergency physiotherapy and orthopaedics departments was supported. Referral times from the emergency department to the clinic and from the clinic to obtaining a scan were significantly shortened. Patient satisfaction was high.

In the ambulatory care assessment unit, a series of “hot clinics” for specific specialties were held throughout the week, which included: stroke; respiratory; neuro medicine; gastro; renal; and infectious diseases. The unit also held a hot clinic to reassess patients to avoid admission.

A programme of trauma and resuscitation team skills training was commenced in January 2018 to support learning for nursing staff in the care of major trauma patients, to meet a requirement for all nursing staff to be level one compliant during 2018.

The emergency department introduced in situ simulation to support the communication of lessons learnt from challenging cases that were highlighted to the department from complaints or serious untoward incidents. Simulated scenarios ran from 8am to 10am for one morning each month. The scenarios were followed by an immediate debrief of the case. In situ simulation could be cancelled when the work situation in the department required. A one-page newsletter of lessons learned was prepared within 24 hours and sent to all staff electronically. Feedback was given to a patient that an in situ simulation learning event took place after their complaint. The patient was satisfied with this being part of the action plan following the incident they were involved in.

The role of the professional practice and development lead for the emergency department was compliance with mandatory training. As part of this role, the practice development lead arranged “sweeper” days in which mandatory and other training was planned as part of the staff rota.

The clinical emergency medicine application for mobile devices recently implemented in the emergency department as a reporting tool with action cards provided an online situation report linked to electronic action cards for key operational medical and nursing staff and provided live updates. The application enabled key performance information to be shared by senior medical and nursing staff and supported staff members in responding quickly to mitigate identified risks to patients.

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Medical care (including older people’s care)

Facts and data about this service

Bradford Teaching Hospitals NHS Foundation Trust is an integrated trust, which provides acute and community health inpatient services. The trust serves a population of around 500,000 people from Bradford and surrounding area.

The acute services are provided in two hospitals, Bradford Royal Infirmary and St Luke’s Hospital. The community health inpatient services in Bradford are provided in three community hospitals; these are Westwood Park, Eccleshill and Westbourne Green. The medicine core service at the trust provides care and treatment for elective and acute services, as well as an out- reach dialysis service located in Skipton and a cardiology out-patient clinic in Addingham.

Activity from July 2016 to July 2017

There are a total of 724 in-patient beds. The trust employs 5,028 WTE staff.

Bradford Royal Infirmary: There are 321 beds located within 15 wards.

(Source: Routine Provider Information Request)

The trust had 49,441 medical admissions from August 2016 to July 2017. Emergency admissions accounted for 24,548 (50%), 1,514 (3%) were elective, and the remaining 23,379 (47%) were day case.

Admissions for the top three medical specialties were:

 General medicine: 12,836 admissions  Gastroenterology: 12,230 admissions  Geriatric medicine: 7,375 admissions

(Source: Hospital Episode Statistics)

We inspected the whole core service and looked at all five key questions. In order to make our judgements, we visited 13 wards and spoke with 10 and 27 staff from different disciplines, including doctors, nurses, allied health professionals and health care assistants. We observed daily practice and viewed 26 sets of records. Before and after our inspection, we reviewed performance information about the trust and reviewed information provided to us by the trust.

We visited the following wards during our inspection:  Ward 1 acute medical unit (AMU)  Ward 3 elderly assessment unit (EAU)  Ward 4 acute medical unit (AMU)  Ward 6 stroke and neurology  Ward 7 haematology  Ward 9 renal and short stay  Ward 19 discharge lounge  Ward 22 coronary care  Ward 23 respiratory  Ward 24 infectious diseases  Ward 29 elderly care

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 Ward 31 elderly care  Cardiac catheter lab

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 Mandatory training completion rates The trust set target rates of 75% and 95%, dependant on the course, for the completion of mandatory training.

The trust was not meeting its target in many of the training areas and the nursing staff group showed the lowest compliance. The trust failed to meet their target for 22 of the 29 courses in the nurse staffing group at Bradford Royal Infirmary with an overall 66% compliance rating for this group. However the medical and dental staff group showed a slightly better compliance rate at 78%, but still failed to reach the trust target rate in 12 out of 20 courses.

A breakdown of compliance for mandatory courses from April 2016 to March 2017 for medical/dental and nursing/midwifery staff in medicine both at trust level and for Bradford Royal Infirmary is shown below:

Medical and dental staff – Trust-wide Staff Staff Completion Trust Target Course title trained eligible rate Target met? Naso Gastric (NG) Tube Care & 3 3 100% 75% Yes Administration - General Naso Gastric (NG) Tube Placement Self 3 3 100% 75% Yes Certification - General Equality & Diversity for Managers - General 2 2 100% 95% Yes Communication Improvement using the 84 91 92% 75% Yes SBAR Technique - General Safe Administration and Preparation of 61 67 91% 75% Yes Injectables - General Acute Kidney Injury (AKI) - General 32 36 89% 75% Yes Diabetes Care and Safe Use of Insulin - 55 66 83% 75% Yes General NEWS/PAWS/NeoNate Observation Theory 55 66 83% 75% Yes - General Introduction to Equality & Diversity - 146 159 92% 95% No General Infection Control - No Renewal 150 168 89% 95% No Corporate Induction 146 168 87% 95% No Information Governance - 1 Year 146 168 87% 95% No Health and Safety - 2 Years 133 168 79% 95% No Fire Safety - 2 Years 49 62 79% 95% No Moving & Handling Low Risk - General 127 168 76% 95% No Collecting Blood Competency Assessment - 7 11 64% 75% No 2 Year

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Infection Control - 1 Year 31 67 46% 95% No Blood Transfusion - 1 Year 26 62 42% 75% No Fire Safety - 1 Year 44 106 42% 95% No Adult Basic Life Support - 1 Year 26 66 39% 75% No Dangers of Misplaced Naso Gastric (NG) 0 1 0% 75% No Tube (NPSA Alert) - General

The overall completion rate for medical and dental staff trust-wide was 78%. The trust failed to meet their target for 13 of the 21 courses.

Medical and dental staff – Bradford Royal Infirmary Staff Staff Completion Trust Target Course title trained eligible rate Target met? Naso Gastric (NG) Tube Placement Self 3 3 100% 75% Yes Certification - General Naso Gastric (NG) Tube Care & 3 3 100% 75% Yes Administration - General Equality & Diversity for Managers - 1 1 100% 95% Yes General Safe Administration and Preparation of 52 55 95% 75% Yes Injectables - General Communication Improvement using the 68 72 94% 75% Yes SBAR Technique - General Acute Kidney Injury (AKI) - General 27 29 93% 75% Yes Diabetes Care and Safe Use of Insulin - 48 54 89% 75% Yes General NEWS/PAWS/NeoNate Observation 47 54 87% 75% Yes Theory - General Introduction to Equality & Diversity - 93 104 89% 95% No General Infection Control - No Renewal 132 148 89% 95% No Corporate Induction 128 148 86% 95% No Information Governance - 1 Year 128 148 86% 95% No Health and Safety - 2 Years 117 148 79% 95% No Fire Safety - 2 Years 42 54 78% 95% No Moving & Handling Low Risk - General 113 148 76% 95% No Collecting Blood Competency Assessment 6 10 60% 75% No - 2 Year Infection Control - 1 Year 25 55 45% 95% No Blood Transfusion - 1 Year 20 48 42% 75% No Fire Safety - 1 Year 39 94 41% 95% No Adult Basic Life Support - 1 Year 19 54 35% 75% No

The overall completion rate for medical and dental staff at Bradford Royal Infirmary was 78%. The hospital failed to meet their target for 12 of the 20 courses.

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Nursing and midwifery staff – Trust-wide Staff Staff Completio Trust Target Course title trained eligible n rate Target met? Strategic Risk Management 3 3 100% 75% Yes Dangers of Misplaced Naso Gastric (NG) 5 5 100% 75% Yes Tube (NPSA Alert) - General Naso Gastric (NG) Tube Placement Self 1 1 100% 75% Yes Certification - General Safe Administration of Medicines - 147 184 80% 75% Yes Competence Assessment - General Diabetes Care and Safe Use of Insulin - 305 384 79% 75% Yes General Communication Improvement using the 346 437 79% 75% Yes SBAR Technique - General Acute Kidney Injury (AKI) - General 10 13 77% 75% Yes NEWS/PAWS/NeoNate Observation Theory 305 398 77% 75% Yes - General Safe Administration of Medicines - 2 Year 372 489 76% 75% Yes Corporate Induction 475 546 87% 95% No Infection Control - No Renewal 473 546 87% 95% No Introduction to Equality & Diversity - General 598 694 86% 95% No Information Governance - 1 Year 426 546 78% 95% No Health and Safety - 2 Years 370 546 68% 95% No Infection Control - 1 Year 364 546 67% 95% No Venous Thromboembolism - No Renewal 259 391 66% 75% No Naso Gastric (NG) Tube Care & 32 49 65% 75% No Administration - General Moving & Handling Low Risk - General 340 546 62% 95% No Adult Basic Life Support - 1 Year 321 525 61% 75% No NEWS/PAWS/NeoNate Observation 229 384 60% 75% No Competence Assessment - General Fire Safety - 1 Year 319 546 58% 95% No Conflict Resolution - 3 Years 296 516 57% 95% No Collecting Blood Competency Assessment - 172 321 54% 75% No 2 Year Equality & Diversity for Managers - General 9 17 53% 95% No Blood Transfusion - 1 Year 95 188 51% 75% No Moving & Handling Medium/High Risk - 170 399 43% 95% No General Preparing to Administer/Administering Blood 98 262 37% 75% No - 3 Year Organising Receipt of Blood - 3 Year 88 262 34% 75% No Collecting Blood/Blood Components Theory 1 4 25% 75% No - 1 Year

The overall completion rate for nursing and midwifery staff trust-wide was 68%. The trust failed to meet their target for 20 of the 29 courses.

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Nursing and midwifery staff – Bradford Royal Infirmary Staff Staff Completio Trust Target Course title trained eligible n rate Target met? Strategic Risk Management 3 3 100% 75% Yes Dangers of Misplaced Naso Gastric (NG) Tube (NPSA Alert) - General 5 5 100% 75% Yes Naso Gastric (NG) Tube Placement Self Certification - General 1 1 100% 75% Yes Safe Administration of Medicines - Competence Assessment - General 109 140 78% 75% Yes Communication Improvement using the SBAR Technique - General 260 337 77% 75% Yes Diabetes Care and Safe Use of Insulin- General 214 281 76% 75% Yes Acute Kidney Injury (AKI) - General 9 12 75% 75% Yes Corporate Induction 355 419 85% 95% No Infection Control - No Renewal 353 419 84% 95% No Introduction to Equality & Diversity - General 396 479 83% 95% No Information Governance - 1 Year 329 419 79% 95% No NEWS/PAWS/NeoNate Observation Theory - General 235 317 74% 75% No Safe Administration of Medicines - 2 Year 266 365 73% 75% No Health and Safety - 2 Years 276 419 66% 95% No Naso Gastric (NG) Tube Care & Administration - General 32 49 65% 75% No Infection Control - 1 Year 272 419 65% 95% No Venous Thromboembolism - No Renewal 183 283 65% 75% No Equality & Diversity for Managers - General 7 11 64% 95% No Moving & Handling Low Risk - General 261 419 62% 95% No Adult Basic Life Support - 1 Year 233 400 58% 75% No Fire Safety - 1 Year 241 419 58% 95% No Conflict Resolution - 3 Years 223 392 57% 95% No NEWS/PAWS/NeoNate Observation Competence Assessment - General 175 308 57% 75% No Collecting Blood Competency Assessment - 2 Year 149 282 53% 75% No Blood Transfusion - 1 Year 84 175 48% 75% No Moving & Handling Medium/High Risk - General 127 302 42% 95% No Preparing to Administer/Administering Blood - 3 Year 78 233 33% 75% No Organising Receipt of Blood - 3 Year 69 233 30% 75% No Collecting Blood/Blood Components Theory - 1 Year 1 4 25% 75% No

The overall completion rate for nursing and midwifery staff at Bradford Royal Infirmary was 66%. The hospital failed to meet their target for 22 of the 29 courses.

(Source: Routine Provider Information Request (RPIR) P40 – Statutory and Mandatory Training)

Staff mandatory training rates were not compliant with the trust’s targets. The figures received from the trust showed that key mandatory training areas such as fire safety, health and safety, equality and diversity, infection prevention and control and moving and handling showed low

20171116 900885 Post-inspection Evidence appendix template v3 Page 85 compliance across all staff groups. The trust was not meeting its own targets in relation to mandatory training in the majority of subjects.

Staff we spoke with told us that staffing pressures and the introduction of the electronic patient record (EPR) system had impacted on their ability to complete mandatory training.

Compliance for key competency mandatory training around the collection, storage and handling of bloods and blood transfusions was also low. However, we spoke to staff on the wards that handled blood regularly and they told us they were up to date with their training and had time to complete mandatory training. We were not assured that this was correct when supplied with more up to date figures on compliance, as shown below.

Preparing to Organising Receipt of Collecting Bloods - Administer/Administering Total Number of Staff on Ward Area Bloods - All Staff of Bloods - Registered Ward Registered Nurses Nurses 17% 33% 33% RN - 11 7 Haematology not compliant not compliant not compliant HCA - 5 9 Renal and 43% 64% 53% RN - 17 Short stay not compliant not compliant not compliant HCA - 13 18% 46% 16% RN - 10 15 Oncology not compliant not compliant not compliant HCA - 13 Haematology and 18% 14% 14% RN - 7 Oncology daycase not compliant not compliant not compliant HCA - 4 42 Acute Dialysis 33% 27% 22% ADU at BRI is staffed by the (ADU) not compliant not compliant not compliant main dialysis unit at SLH The trust reported that there are contingencies to ensure that areas are staffed with nurses who have completed the training including:  Review of skill sets at the daily huddle  The staff with the skill set are identifiable on e-roster  Current staffing rosters take into consideration having staff on duty that can check and administer blood.  Should there be an unplanned gap; staff are swapped accordingly to ensure the skill can be delivered.  These wards are focusing on training all staff. There are key assessors on Ward 15 and Ward 7 who also cover the clinical unit.  There are no investigations; incidents or complaints that have cited transfusion delays as an issue.  There has been no escalation of concern or safety related concerns raised through directorate or divisional governance relating to this issue.  Training is part of divisional mandatory training sweeper days and the clinical educator targets areas of poor compliance with both the annual and alternate year competencies relating to this subject (Source: Data request MED10 Competency Assessment) Safeguarding Staff understood and were able to explain how to raise a safeguarding concern if they thought a patient maybe at risk of harm. Nursing and medical staff we spoke with were able to explain the process for safeguarding a patient and provided us with specific examples as to when they would do this. We saw that staff were able to access the trust safeguarding guidelines, which were readily available on the intranet.

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Junior staff told us any safeguarding concerns were escalated to a senior nurse and doctor. Staff told us they could access the trust’s internal safeguarding team for advice and guidance if they were unsure about whether an issue was a safeguarding concern. Staff were aware of safeguarding processes for child exploitation and female genital mutilation (FGM), however did say that given their area of work (elderly medicine), it was unlikely they would routinely encounter these issues. Safeguarding training completion rates The trust set a target rate of 95% for the completion of safeguarding training. The trust were not meeting their agreed targets for safeguarding training in any of the courses delivered to the nursing staff group and failed to meet targets in three of the four safeguarding courses delivered to medical staff.

A breakdown of compliance for safeguarding courses from April 2016 to March 2017 for medical/dental and nursing staff in medicine both trust-wide and at Bradford Royal Infirmary is shown below:

Medical and dental staff – Trust-wide Staff Staff Completion Trust Target Course title trained eligible rate Target met? Safeguarding Adults Level 2 - 3 Years 5 5 100% 95% Yes Safeguarding Children Level 1 - 3 Years 142 168 85% 95% No Safeguarding Children Level 2 - 3 Years 58 69 84% 95% No Safeguarding Adults Level 1 - 3 Years 120 168 71% 95% No

The overall completion rate for medical and dental staff trust-wide was 79%. The trust failed to meet their target for three of the four courses.

Medical and dental staff – Bradford Royal Infirmary Staff Staff Completion Trust Target Course title trained eligible rate Target met? Safeguarding Adults Level 2 - 3 Years 2 2 100% 95% Yes Safeguarding Children Level 1 - 3 Years 124 148 84% 95% No Safeguarding Children Level 2 - 3 Years 47 57 82% 95% No Safeguarding Adults Level 1 - 3 Years 105 148 71% 95% No

The overall completion rate for nursing and midwifery staff at Bradford Royal Infirmary was 78%. The hospital failed to meet their target for three of the four courses.

Nursing and midwifery staff – Trust-wide Staff Staff Completion Trust Target Course title trained eligible rate Target met? Safeguarding Adults Level 1 - 3 Years 447 546 82% 95% No Safeguarding Children Level 1 - 3 Years 437 546 80% 95% No Safeguarding Adults Level 2 - 3 Years 431 542 80% 95% No Safeguarding Children Level 2 - 3 Years 433 546 79% 95% No Safeguarding Adults Level 3 - 3 Years 7 12 58% 95% No Safeguarding Children Level 3 - 1 Year 0 1 0% 95% No

The overall completion rate for nursing and midwifery staff trust-wide was 80%. The trust failed to meet their target for all six courses. 20171116 900885 Post-inspection Evidence appendix template v3 Page 87

Nursing and midwifery staff – Bradford Royal Infirmary Staff Staff Completion Trust Target Course title trained eligible rate Target met? Safeguarding Adults Level 1 - 3 Years 333 419 79% 95% No Safeguarding Children Level 1 - 3 Years 324 419 77% 95% No Safeguarding Adults Level 2 - 3 Years 319 416 77% 95% No Safeguarding Children Level 2 - 3 Years 320 419 76% 95% No Safeguarding Adults Level 3 - 3 Years 7 12 58% 95% No

The overall completion rate for nursing and midwifery staff at Bradford Royal Infirmary was 77%. The hospital failed to meet their target for all five courses.

(Source: Routine Provider Information Request (RPIR) P40 – Statutory and Mandatory Training) Cleanliness, infection control and hygiene We observed that staff adhered to the infection control policy and used personal protective equipment (PPE), such as plastic aprons and gloves, when delivering personal care to patients. We observed medical and nursing staff following the trust policy for hand washing and ‘bare below the elbows’ guidance in clinical areas. Staff used colour coded aprons for patients in a side room which meant they could be identified and challenged if seen on the main ward in the same apron. We saw that sluices were clean and tidy and checked three commodes. These had been cleaned and had labels in place to identify that they had been cleaned. Due to the ongoing issues within the environment, patients could not be isolated. For example one patient was required to be isolated in the cardiac care unit (CCU) however there were no facilities. On ward 22 there was one sink to eight patients. Staff were expected to rely heavily on the use of alcohol gel. The infection control team were working with the wards to review and manage the lack of single room facilities. Staff would incident report times where they had not been able to appropriately isolate patients. These included three incidents in May 2017 where patients should have been isolated. Throughout Bradford Royal Infirmary we saw that there needle sharp bins for the disposal of contaminated needles. These were easily accessed by staff. Changes had been made on ward 24 since our last inspection. Equipment was stored appropriately and not on the floor. The dinner trolley was stored previously outside the staff toilet; this had now been moved and stored near to the kitchen. Changes were due to be made to the kitchen to allow the kitchen trollies to be stored in the kitchen. Infection prevention and control audits were conducted on a monthly basis, where results were low, the infection prevention and control team would work with the ward on an action plan for improvement. We had concerns around the storage of equipment in the vestibule of the discharge lounge. The trust had risk assessed this but had not considered any potential issues with infection control and being able to ensure that cleaning was done appropriately around and under the equipment in this area. Environment and equipment We checked medicines and equipment for emergency use and found they were readily available;

20171116 900885 Post-inspection Evidence appendix template v3 Page 88 staff carried out regular checks to ensure these were fit for use in line with the trust policy. We visited ward 19, the discharge lounge, which was located on level 4 at the far side of the hospital. The ward was not located near the main entrance or on ground level, so patients being discharged to patient transport services would need to be collected and transported in the lift and wheeled or walked through the hospital to exit. Whilst we were on the ward a patient was organising their collection with a relative and commented that it was not the easiest location to explain to family picking them up. We observed that signage throughout the hospital was an issue and we had to ask a member of staff for directions to the discharge lounge. We asked whether the trust had received any complaints about the discharge lounge and we were told there had been two complaints:  September 2017 complaint about issues with waiting for transport and medication not being given.  December 2017 complaint about waiting for patient transport and the patient felt uncared for. We did not feel that the location of the discharge lounge was appropriate for all patients awaiting discharge, due to the location and the appearance of the ward. There was not a dedicated room for private conversations around discharge and medicines, however staff told us they could utilise the male waiting room if it was not in use. The trust did not monitor or collect data on how long patients waited in the discharge lounge. The entrance to the discharge lounge had a large vestibule space that had been filled with three hospital beds, several cages of chairs and other equipment that had been located there whilst another ward was being refurbished. The equipment was placed as far against the wall as possible however the equipment still posed a risk to health and safety for staff and patients, and was an infection control risk as we were not assured that the equipment could be moved to clean the area properly. We did not see a risk assessment at the time of our inspection but requested a copy after the inspection. The trust had risk assessed the storage of equipment in the area in November 2017 and rated it as low risk. However the risk assessment failed to take in to account issues with cleaning around and under the equipment so we were not assured that robust infection prevention and control measures had been considered, other than the potential of legionella in under used water sources in this area. Our last inspection had identified that there were issues with the environment of medical wards particularly with access to en-suite facilities and infection control. The environment remained unchanged on ward 24 however they were due to move to ward 7 in February 2018 where all the rooms would have en-suite facilities. Changes to the toilet areas had been approved and were due to be changed in February 2018. The rooms on ward 6 (stroke and neurology) did not have any en-suite facilities so patients were required to use the same bathroom facilities on the ward. We found most ward areas appeared clean and tidy, however a member of our inspection team did observe some environmental issues on our second visit to ward 3. There were mattresses scattered on the floor of the equipment room, propping open the door and potentially impeding access to equipment. There were also multiple electronic patient record (EPR) trolleys being stored at the ward entrance, almost entirely blocking the doorway, which could be a hazard in the event of evacuating the ward. We had visited ward 3 previously and had not found these issues the first time. On ward 31 (elderly care) there were single rooms available with ensuite facilities. This included two isolation rooms where patient could be quarantined. The rooms had their own ventilation system. We saw that one of the rooms had a fault on the ventilation keyboard and this had not been reported to the engineering department. The ward did not keep an audit of the ventilation; we found that the following day the fault light was still active on the keyboard. We checked that equipment had been serviced. We checked 11 items including suction 20171116 900885 Post-inspection Evidence appendix template v3 Page 89 machines, hoists and medication pumps and found 10 had been serviced. We highlighted the one item that had not been serviced with the ward manager who assured us that this would be completed. We checked the resuscitation trolleys on each ward and found the majority were checked daily. Ward 6 and ward 24 had some occasions where the trolley had not been checked daily. The trolley on ward 6 had daily checks missing for seven days between October 2017 and January 2018. The trolley on ward 24 had daily checks missing for nine days between November 2017 and December 2017, however none of these occasions were consecutive days. Assessing and responding to patient risk We found that all patients we reviewed had been appropriately assessed for the risk of Venous Thromboembolism (blood clots) and appropriate prophylaxis had been prescribed where this was indicated. The elderly care wards (ward 29 and ward 31) had CCTV in operation. Ward 31 had specialised cushioned flooring to reduce the impact of falls. We saw that patients had falls sensors in place that would alarm if triggered. These clipped on to the patient’s body or clothing. Ward 3 elderly assessment unit nursed poorly patients in beds near the nurses’ station so they could be visually monitored. The ward also recorded patients’ latest NEWS scores on the patient board so a deteriorating patient could be identified and escalated quickly. A leaf system was in place for patients at risk of falling. The colour of leave changed depending on the level of risk. A red leaf meant the patient had had a fall, and amber leaf denoted a patient was at risk of a fall. We spoke with domestic staff that had an understanding on the system and could discuss what actions they would take. We looked at four patients with a falls risk assessment and saw that they all had the falls sensors in place. The electronic patient record (EPR) included risk assessments covering falls assessments and a post fall evaluation assessment. Staff completed the NEWS score; this was recorded on the patient’s EPR. Staff felt that the medical staff responded to patients with elevated NEWS scores. We saw behaviour contracts in place between patients and staff on ward 24 (infectious diseases). This allowed patients who attended the ward to be aware of the boundaries that were set. On ward 29 there was a call bell monitor located behind the nursing station. When call bells sounded they showed on screen as amber with a timer counting how long a bell had been sounding. Once the call was answered they would show as green on the screen. We observed a call bell sounding from a side room at 9.10am, from the point of observation it had been sounding for 3:46 minutes. The bell was answered after sounding for 9 minutes. We were not assured that patients were always promptly responded to when sounding the call bells, however we observed other call bells on the ward were answered promptly. There was no specialist respiratory consultant presence at the weekend. Patients on the respiratory high dependency unit on ward 23 could be seen by an on call consultant from the AMU consultant team and in reach support from critical care could be accessed if needed. There was a vacancy for a respiratory consultant so the team was not at full capacity. Whilst on inspection we were not assured that the trust had fully considered the risk around the lack of specialist medical presence; however the trust provided a standard operating procedure (SOP) for the ward and a risk assessment post inspection. The SOP provided detailed information for the management of patients on Non Invasive Ventilation. There was a clear escalation process for patients who needed medical input out of hours and support from an ICU consultant could be accessed. We saw that the patient’s wristbands contained a bar code scanner which was used as part of the medication process. Intentional rounding had been consistently completed in the records we reviewed. Intentional rounding is a formal system used to periodically check on patients in order to improve patients’

20171116 900885 Post-inspection Evidence appendix template v3 Page 90 experience and ensure that care is safe and reliable. Each staff member was provided with an electronic summary of each patient. This included the reason for admission, required investigations and any ongoing care they required. We saw that staff referred to the sheets for information. The information was updated on a daily basis. Staff receive a safety brief each morning, this included patients at risk of fall, pressure ulcers and admissions. Safety huddles were completed daily after the medical ward round. Each member of staff on duty on the ward was expected to attend including the ward clerk, domestic and nursing staff. We observed the safety huddle on ward 29 and found that all the staff attended and were given the opportunity to ask or raise any questions and concerns. Suitable patients could be discharged to their home and cared for by the multi-skilled ‘virtual ward’ team. There were no formal criteria for treatment by the ‘virtual ward’ team; however medical staff used their clinical judgement to assess whether the patient was suitable for the service. Nurse staffing There were a high number of nurse staffing vacancies across the division. Figures from September 2017 showed 83 whole time equivalent (WTE) nursing vacancies. However, nurse staffing was well managed on a daily basis using a safer staffing tool and gaps in cover were discussed at the daily ‘matron huddle’. Staff from some areas were protected (A&E and the HASU) so could not be moved, but staff from other areas were often moved to other wards when planned numbers fell below safe staffing levels. Staffing was reviewed throughout the day at the relevant meetings. Wards were RAG rated and staff were moved to different areas in accordance to need and rating. Where staff required particular competencies, for example in the hyper acute stroke unit (HASU), staff from ward 6 (stroke and neurology) would be moved on to the HASU and a nurse from another area would fill the gap on ward 6, unless the shift was downgraded and an additional health care assistant was used to support the nurses on the ward. Downgrading shifts was in use across the service. We visited ward 3 elderly assessment unit, on the day of our inspection they were two registered nurses short for the day shift and three health care assistants (HCAs) short. For the night shift there had been an increase of one HCA as there was one less registered nurse. We visited ward 6, on the day of our inspection for all three shifts there was reduced numbers of registered nurses. The midday shift was two registered nurses short. Extra health care assistants had been recruited due to the low numbers of registered nurses. We visited ward 31, on the day of our inspection there was one registered nurse short for both the afternoon and night shift. Health care assistants were at the required level for two of the three shifts. On the day of inspection there were six patients in the hyper acute stroke unit (HASU) with two registered nurses and one health care assistant. One of these was the stroke responder who would need to attend the emergency department (ED) in the event of a patient arriving with a stroke. The stroke responder was required on the day of inspection to attend ED for approximately two hours. In this time another staff member from the ward covered the HASU. One of the registered nurses told us that they were looking after three patients in the HASU. The HASU operated on a 1:2 ratio. This means there is one registered nurse for two level 2 patients on the unit. We reviewed staffing data that detailed the number of registered nursing staff and the number of level 2 patients on the unit from the 20 November 2017 to 15 January 2018. The staffing had met the 1:2 ratio on every day. Data had not been supplied for the 10 January 2018 so we were unable to confirm the ratio on this date.

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A staff review was completed in December 2017 and identified that the cardiac catheter lab required extra staff to be appropriately equipped. This included one full time band 6 nurse and extra band 5 nurse hours. Most staff we spoke to felt they received an adequate induction period. On one ward some nurses told us that due to staff shortages they had been included in the numbers when they should have been on a supernumerary period. A period of supernumerary practice is to allow adequate time for registered nurses to develop basic skills and competencies to safely care for patients on their base ward. We spoke to bank and agency staff who worked several shifts a week. They felt that they were supported and had received an adequate induction to the ward areas they worked on. The trust reported the following nursing staffing numbers as of September 2017 for medicine:

Ward/Site Planned staff (WTE) Number in post (WTE) Bradford Royal Infirmary 427 344 Eccleshill Community Hospital 12 2 St Luke's Hospital 73 65 Westbourne Green Community Hospital 12 11 Westwood Park Community Hospital 12 9 Total 534 431

(Source: Routine Provider Information Request (RPIR) – P16 Total numbers – Planned vs actual tab)

The following nurse staffing information is routinely requested within the universal provider information request spreadsheets, to be completed within a standard template.

Vacancy rates From October 2016 to September 2017, the trust reported an overall vacancy rate of 18% for nursing staff in medicine. The trust did not record a target vacancy rate for this period.

Bradford Royal Infirmary Bradford Royal Infirmary reported a vacancy rate among nursing and midwifery staff in medicine of 26% from October 2016 to September 2017.

(Source: Routine Provider Information Request (RPIR) P17 Vacancies)

Turnover rates From October 2016 to September 2017, the trust reported an overall turnover rate of 14% for nursing staff in medicine. The trust did not record a target turnover rate for this period.

Bradford Royal Infirmary Bradford Royal Infirmary reported a turnover rate among nursing and midwifery staff in medicine of 11% from October 2016 to September 2017.

(Source: Routine Provider Information Request (RPIR) P18 Turnover)

Sickness rates From October 2016 to September 2017, the trust reported an overall sickness rate of 5% for 20171116 900885 Post-inspection Evidence appendix template v3 Page 92 nursing staff in medicine which was higher than the trust target of 4%.

Bradford Royal Infirmary Bradford Royal Infirmary reported a sickness rate among nursing and midwifery staff in medicine of 4% from October 2016 to September 2017, which was the same as the trust target.

(Source: Routine Provider Information Request (RPIR) P19 Sickness)

Bank and agency staff usage Please note that we have been unable to calculate bank and agency usage as a proportion of the total number of shifts available including those covered by permanent staff due to the fact that the total number of bank and agency shifts reported by the trust was often higher than the total number of available shifts.

From October 2016 to September 2017, the trust reported bank usage for registered nurses in medicine of 5,729 shifts and agency usage of 7,301 shifts. There were 3,751 shifts that were unfilled by bank and agency staff. All of these shifts were at Bradford Royal Infirmary.

(Source: Routine Provider Information Request (RPIR) P20 Nursing – Bank and Agency)

Medical staffing The division had some medical staffing vacancies, however staff told us they felt well supported. Junior doctors told us that the consultants provided effective leadership and had been able to learn on the wards. The trust had some academic professorial staff working in clinical roles which would enrich the learning opportunities for junior staff. Each speciality had its own arrangements for core hours and on call cover. Consultant cover per speciality Renal Service The service operates a consultant of the week model. In core hours Monday to Friday 8am - 5pm there is an on-site renal consultant of the week. After 5pm this is an on call service until 8am the next morning provided by renal on call consultant. During weekends and bank holidays the renal on call consultant is on site, and then an on call service is provided overnight. Acute Medicine AMU has consultant presence on the unit Monday to Friday until 9pm and then it becomes an on call service overnight. On a weekend and bank holiday the on call consultant is on site from 8pm – 5pm supported by a second consultant 8am – 2pm. This then becomes an on call service. Acute Stroke The acute stroke service runs two on call rotas 7 days a week, 52 weeks a year. • Consultant support for the wards in Bradford and Airedale as well as for advice for non-thrombolysis patients. • Regional consultant on call for patients requiring thrombolysis treatment. Geriatric Monday to Friday 8am until 5pm on site and then it becomes an on call service Medicine until the next morning. During weekends and bank holidays an on call consultant is on site from 8am – 4pm and this then becomes an on call service.

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Cardiology The service operates a consultant of the week model. In core hours Monday to Service Friday 8am - 5pm on site cardiology consultant of the week delivered on ward 22. After 5pm this is an on call service until 8am the next morning provided by a cardiology on call consultant. During weekends and bank holidays the cardiology on call consultant is on site, and then an on call service is provided overnight. Medical Monday to Friday between 8am - 5pm there are two medical oncology Oncology consultants each day who are timetabled to provide up to 1PA each of ward cover. This includes review of acute admissions to medical oncology and review of the medical oncology in-patients. Out of hours and at weekends there is a non-resident medical oncology consultant on-call rota. In-patients are reviewed on a Saturday and Sunday by a specialist trainee in medical oncology and the medical oncology consultant is available for advice but does not undertake a ward round. Neurology There is consultant presence on the ward 8am - 5pm. The consultants do not provide on-call cover out of hours, weekends and bank holidays.

Haematology There is consultant presence on the Ward 8am - 5pm, the consultants provide telephone on-call cover for out of hours, weekends and bank holidays

Infectious Monday to Friday 8am - 5pm on site infectious diseases consultant cover Diseases provided on inpatient infectious diseases ward 24. This becomes an on call service until next morning through the AMU Consultant team. Infection Control/HIV cover is provided 1 in 4 with trust rota for HIV & contamination injury service. During weekends and bank holidays an on call Consultant is on site from the AMU consultant team for the inpatient ward. Respiratory Monday to Friday 8am - 5pm on site respiratory consultant cover provided on inpatient respiratory ward 23. This becomes an on call service until next morning through AMU consultant team. During weekends and bank holidays an on call consultant is on site from AMU consultant team for the inpatient ward. (Source: Information taken from MED29 consultant cover data request) The trust has reported the following medical staffing numbers as at September 2017 for medicine:

Ward/Site Planned staff (WTE) Number in post (WTE) Bradford Royal Infirmary 118 123 St Luke's Hospital 4 4 Westbourne Green Community Hospital 0.5 0.5 Total 123 127

(Source: Routine Provider Information Request (RPIR) – P16 Total numbers – Planned vs actual tab)

The following medical staffing information is routinely requested within the universal provider information request spreadsheets, to be completed within a standard template.

Vacancy rates From October 2016 to September 2017, the trust reported an overall medical and dental staff vacancy rate of 10% in medicine. The trust did not record a target vacancy rate for this period.

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Bradford Royal Infirmary Bradford Royal Infirmary reported a vacancy rate among medical and dental staff in medicine of 10% from October 2016 to September 2017.

(Source: Routine Provider Information Request (RPIR) P17 Vacancies)

Turnover rates From October 2016 to September 2017, the trust reported an overall medical and dental staff turnover rate of 11% in medicine. The trust did not record a target turnover rate for this period.

Bradford Royal Infirmary Bradford Royal Infirmary reported a turnover rate among medical and dental staff in medicine of 12% from October 2016 to September 2017.

(Source: Routine Provider Information Request (RPIR) P18 Turnover)

Sickness rates From October 2016 to September 2017, the trust reported an overall medical and dental staff sickness rate of 2% in medicine, this is lower than the trust’s target overall sickness rate of 4%.

Bradford Royal Infirmary Bradford Royal Infirmary reported a sickness rate among medical and dental staff in medicine of 2% from October 2016 to September 2017, which was lower than the target rate of 4%.

(Source: Routine Provider Information Request (RPIR) P19 Sickness)

Bank and locum staff usage

From October 2016 to September 2017, the trust reported bank usage for medical staff in medicine of 405 shifts and locum usage of 1,778 shifts. There were 453 shifts that were unfilled by bank and locum staff. All of these shifts were at Bradford Royal Infirmary.

(Source: Routine Provider Information Request (RPIR) P21 Medical Locums)

Staffing skill mix In August 2017, the proportion of consultant staff reported to be working at the trust was slightly lower than the England average and the proportion of junior (foundation year 1-2) staff was notably higher.

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Staffing skill mix for the 183 whole time equivalent staff working in medicine at Bradford Teaching Hospitals NHS Foundation Trust This England Trust average Consultant 38% 41% Middle career^ 4% 6% Registrar group~ 25% 30% Junior* 33% 23%

^ 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 (01/08/2017 - 31/08/2017))

Records We saw that patient’s records were secured safely with key code access. Computers were accessible on some of the wards in the bays, to allow access to the patients’ electronic patient record (EPR). We looked at 26 electronic patient records. All the risk assessments and charts were stored on the electronic record. We found that all the records had the appropriate risk assessments completed. In eight records we found that the patient’s nutritional score was not completed. One patient had refused to have their weight recorded and this was documented in the record. Intentional rounding was also recorded on the EPR. We reviewed the record keeping for information inputted by nursing, medical and allied health professionals and found that it recorded relevant information. The EPR had been recently introduced and staff were still learning how to navigate the system as there were various areas to input information. For example some areas had devised an ongoing progress report for each day where information could be added on the patient’s condition rather than each individual staff members documenting on a different form. This meant that it was easier to read and understand the patient’s progression or deterioration. The trust’s electronic records system did not include information about patients with mental ill health. However, the local mental health trust’s psychiatric liaison team, which was based at Bradford Royal Infirmary, held records on patients with mental ill health. These records were not accessible by staff at Bradford Royal Infirmary. We looked at 11 of these care records which were in relation to patients admitted in December 2017 and January 2018. They included details of each patient’s initial assessment, diagnosis, mental capacity and details of their care and treatment. We also saw evidence that reviews of the patients’ diagnosis and mental capacity were being undertaken. We asked staff if the lack of access to these records caused difficulties and they said that getting advice from the mental health trust was easy to access and they could either call them or see the psychiatric liaison team in person at any time. Medicines

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Medicines were stored securely and access was restricted to authorised staff. Controlled drugs were appropriately stored and managed, and balance checks were carried out in accordance with the trust policy, with the exception of ward 22 where we found they had not been carried out every week. We checked the storage and monitoring of medicines requiring refrigeration and found they were managed in accordance with trust policy and national guidance. We reviewed 26 patient records and found that medicines reconciliation had been recorded as completed within 24 hours of admission in 15 cases (57.7%). However, in four cases discrepancies had been identified which had not been resolved. For example, a member of the pharmacy team had identified five regular medicines had not been prescribed for one patient. This had not been resolved when we reviewed the record 72 hours later. We spoke to the ward pharmacist who assured us they would follow this up immediately. The trust had taken steps to ensure appropriate antimicrobial use to optimise patient outcomes and to reduce the risk of adverse events and antimicrobial resistance. For example, electronic prescriptions contained indications and stop dates. In addition, where patients had been prescribed intravenous antibiotics, we saw these were regularly reviewed and changed to oral alternatives in a timely manner. The pharmacy inspection team reviewed three patients who were receiving oxygen therapy and found this had not been appropriately prescribed and monitored in two cases. Other inspection team members also found examples of patients being prescribed oxygen but this was not reflected on their records and the details for varying their oxygen prescription was not recorded. This issue was escalated to the trust whilst we were on site and the trust issued a memo via email to all staff to ensure they knew the correct process to follow on the EPR system to ensure oxygen prescriptions were recorded appropriately. Incidents Staff we spoke to were confident that they could identify and report incidents. Staff were aware of how to complete incident forms and received feedback. We were told that staff completed incident forms for pressure ulcers. The trust used an electronic system to report incidents and these were reviewed daily at the ‘matron huddle’. Staff we spoke to told us that managers were responsive to incidents. We saw display boards that shared learning from incidents with staff. We asked staff what types of incidents were reported in relation to patients with ill mental health. These included incidents in which patients had been violent or aggressive or when the police had needed to be contacted. Staff felt they learned from incidents, for example a safety alert had been sent around the wards due to an incident around thickening agents, to ensure that they were not left on patient’s bedsides. The department had a system to ensure patients were informed and given an apology when something went wrong and were told of any actions taken as a result, this is known as the duty of candour. The duty of candour is a regulatory duty that relates to openness and transparency and 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.

Never Events Never Events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. 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.

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From November 2016 to October 2017, the trust reported no incidents classified as never events for medicine.

(Source: NHS Improvement - STEIS (01/11/2016 - 31/10/2017))

Breakdown of serious incidents reported to STEIS In accordance with the Serious Incident Framework 2015, the trust reported 23 serious incidents (SIs) in medicine which met the reporting criteria set by NHS England from November 2016 to October 2017.

Of these, the most common types of incident reported were:

 Pressure ulcer meeting SI criteria with 18 (78% of total incidents)  HCAI/Infection control incident meeting SI criteria with 2 (8% of total incidents)  Suboptimal care of the deteriorating patient meeting SI criteria with 1 (4% of total incidents)  Surgical/invasive procedure incident meeting SI criteria with 1 (4% of total incidents)  VTE meeting SI criteria with 1 (4% of total incidents)

(Source: Strategic Executive Information System (STEIS)) 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 46 new pressure ulcers, 25 falls with harm and 13 new catheter urinary tract infections from October 2016 to October 2017 for medical services.

The trust provided overall safety thermometer data for the previous six months which shows a score out of 100:

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Ward/Unit (Monthly) NHS Patient Safety Thermometer Jul Aug Sep Oct Nov Dec

Acute Medicine AMU 94 94.96 95.78 92.47

Ward 6 97 94.25 97.30 95.43 86.62 98.57

Ward 9 97 96.32 92.10 95.86 97.26 94.74 Spec Med 1 Ward 22/CCU 98 99.39 97.88 98.64 99.58 98.79 Ward 23 99 98.42 97.56 94.60 98.37 96.55

Ward 24 95.77 93.52 97.60 100 95.94

Spec Med 2

Ward 7 98 94.83 100 96.47 92.71 100 Ward 15 96 95.18 93.49 96.22 93.81 92.78 Elderly

Ward 29 97 96.35 97.15 95.60 85.56 95.94

EAU/Ward 3 91 97.38 95.02 98.29 99.04 97.78

Ward 31 91 97.99 94.17 96.70 95.00 96.69 Two ward areas, ward 29 stroke and neurology and ward 29 elderly care, had scores of less than 90 in November 2017. The AMU data is missing for August and September 2017. (Source: data request ‘MED 9 Monthly NHS Patient Safety Thermometer Data’) Prevalence rate (number of patients per 100 surveyed) of pressure ulcers at Bradford Teaching Hospitals NHS Foundation Trust

Total Pressure ulcers (46)

Total Falls (25)

Total CUTIs (13)

Source: Safety thermometer - Safety Thermometer

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Is the service effective? Evidence-based care and treatment There were local pathways in place to support decision making in line with best practice guidance. We saw that these were readily accessible by staff online; however some policies and guidance had gone past their review date. For example the policy for the prevention and management of pressure ulceration and an educational resource book had passed its review date of December 2017, so we were not assured that staff would always be using the most up to date guidance and best practice guidelines. The virtual ward had a number of defined care pathways, a referral process, criteria and clinical governance framework. Pathways included:  Frail elderly discharge to assess (step down)  OHPAT (outpatient home parental antibiotic treatment) ambulatory care pathway (step down)  COPD ambulatory care pathway (step down)  Frail elderly community step-up pathway  YAS falls (FY/Category C) step-up pathway

Patients received an assessment of their risk of a Venous Thromboembolism (blood clot) on admission and were given treatment in line with NICE quality statement (QS) 66. The trust and the hospital were addressing falls prevention using national guidance and data from local and national audits. The trust had a falls prevention multidisciplinary group that met on a monthly basis. We spoke to staff on several wards and they told us they actively worked to ‘end pyjama paralysis’. End pyjama paralysis is a national campaign which encourages hospital patients, where appropriate, to dress in their own clothes and mobilise as much as possible in attempt to aid recovery. We spoke to staff who were able to confidently describe the signs of sepsis and management of sepsis in line with national guidelines. Staff confirmed that they followed the division’s sepsis management guidelines, which included implementation of the sepsis six care bundle along with guidelines for ongoing management. Following the previous inspection in January 2016, the trust was given a requirement notice around the review of policies, procedures and guidance:  The trust must ensure that robust arrangements are in place to ensure that policies and procedures (including local rules in diagnostics) are reviewed and updated. We reviewed 14 policies and guidance documents on the trust intranet and found that of the 14, nine were out of their review date. Policy Name Review Date Non-medical prescribing policy September 2017 Massive haemorrhage guidelines generic adult May 2016 Falls guidelines: prevention and treatment of falls in adult inpatients July 2019 Guidelines on the management of VT February 2012 Guidelines for the management of acute transfusion reactions in adults November 2015 Guidelines for treatment for hypercalcemia in adults November 2019 Cardiopulmonary resuscitation policy March 2018 Chemotherapy procedure for cytotoxic spillages February 2018 MRSA protocol for the management of MRSA March 2018 Anti-microbial prescribing policy October 2015

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Pandemic influenza operational plan May 2010 Management of warfarin reversal for inpatients August 2013 Medical gas operational procedures December 2017 Policy for the prevention and management of pressure ulceration and an December 2017 educational resource book Although improvements had been made since the last inspection and all of the policies we reviewed had an author, date issued and review date on the front page. We were not assured that the trust had a robust system in place to identify and review policies and guidance and as the documents were clearly accessible on the staff intranet there was a risk that staff could access and utilise out of date guidance and policies, which is a potential risk to patient safety. There was no indication on the out of date policies as to whether they were ‘live’ or whether they had been replaced with other policies. Audit results were monitored and used to improve performance and practice on each ward. The division undertook clinical and nursing audits for a variety of subjects. In 2017 the division conducted the following clinical audits:

Audit Date Audit to assess PTWR documentation 04/03/2017 Hepatitis C testing in Haemoglobinopathy 03/04/2017 Haemoglobinopathy Hepatitis B Vaccination 03/04/2017 HIV testing in pnuemonia 10/04/2017 Audit on HIV testing in patients with pneumonia admitted through MAU 26/04/2017 Driving advice in Neurological disorders 13/05/2017 Prescribing Practice (Hospital Palliative care Team) 18/05/2017 Audit of the documentation of lung cancer patients' performance status in the 01/06/2017 MDT record Validation of the National Lung Cancer Audit (NLCA) data for the number of 01/06/2017 patients seen by a lung cancer speciality nurse Dietetic Documentation Audit 06/06/2017 Audit of incidence of moderate to severe psoriasis in Bradford 19/08/2017 Are diabetic foot ulcer patients receiving appropriate cardiovascular risk 14/09/2017 evaluation and management? A Multicenter Retrospective Audit of Native Vertebral Osteomyelitis Cases, 19/09/2017 January 2015 - December 2016 All People who have had a suspected TIA who are at low risk of stroke (that is, 19/10/2017 an ABCD2 score of 3 or below) have been started on 300mg Aspirin daily, Immediately Early post-operative complication rates associated with Cardiac Pacemakers. 16/11/2017 A Retrospective Audit of Transradial Access Site Complication Rates Post 16/11/2017 Percutaneous Coronary Intervention (PCI). Local Audit on VIDEO EEG for PNES standards 30/11/2017 Audit of adherence to nutritional care pathways for patients with #NOF 22/12/2017 (Source: MED13 Clinical local audits 2017 data request) Nursing audits were also completed on the following basis:

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Audit Frequency Dignity and Respect Documented Care 6 monthly Falls Prevention Audit Monthly Fluid Balance Audit Tool Bi-monthly Fridge Audit Tool Monthly Hand Hygiene Monthly NHS Patient Safety Thermometer Monthly Pain Must Falls Audit Monthly SAFE! Discharge Medication Audit Bi-monthly SAFE! NEWS MEWS PAWS Audit tool Bi-monthly SAFE! Oxygen Audit for Adult Patients Bi-monthly SAFE! Patient Identification Inpatients Annual SAFE! Pressure Ulcer Audit Quarterly Think Glucose Monthly Snapshot Audit Monthly (Source: MED13 Nursing audit data last 2 data sets FINAL data request)

Nutrition and hydration We saw that patients had a choice of menu, these included halal, vegetarian, healthy eating and high calorie. The meals arrived on the ward frozen and were cooked on the ward. Pureed food was available and presented well. Patients told us that they had enjoyed the food and that their jugs had been kept filled with water so they were able to stay hydrated. One patient told us ‘the food is excellent for mass catering’. Staff identified patients at risk of malnutrition, weight loss or requiring extra assistance at mealtimes. Staff used the Malnutrition Universal Screening Tool (MUST) tool to identify adults who were malnourished and at risk of malnutrition. We observed that protected meal times were in place and saw patients being supported to eat and drink. Drinks were readily available and were in easy reach of patients. Patients were assessed regarding their nutritional needs and care plans were in place. Systems such as the ‘red tray’ system were in place to identify patients who needed additional support with eating and drinking. In the 2016 NHS adult inpatient survey the trust scored ‘about the same’ as other trusts for the quality of the food and the choice of food, however they scored ‘worse’ than other trusts for help with eating with an overall score of 6.3 out of 10.

(Source: CQC website survey data for Bradford Teaching Hospitals Trust)

Pain relief

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We reviewed patients’ prescriptions and found that pain relief had been appropriately prescribed. Patients we spoke to told us that they had received pain relief in a timely way when it had been requested.

Patient outcomes Wards completed peer reviews such as observing and monitoring the trust’s dress code policy. The results were uploaded and reviewed by the ward managers. The service monitored the effectiveness of care and treatment and used the findings to improve them. There was a ward accreditation programme in use; this covered a number of areas including nutrition, tissue viability, falls, medicines, pain management, patient experience, safeguarding and leadership. Wards were inspected on an unannounced basis and graded red, amber or green with key lines of enquiry linked the CQC domains and the 6 C’s (care, compassion, courage, communication, commitment and competence). Action plans were put in place as appropriate. Ward managers said that this had improved patient safety on the wards. None of the medical wards at Bradford Royal Infirmary had a red RAG rating at the time of the inspection in January 2018. Pressure ulcers, falls and rates of infection were also monitored. Information on performance in areas such as falls, pressure ulcers and infections was reviewed. We were told the trust had a ‘deteriorating patient collaborative’. This was a multidisciplinary group that worked to improve patient outcomes and recognition of a deteriorating patient to avoid escalation to ICU or HDU. Management told us that measures to improve patient outcomes were monitored on a monthly basis. Trust level From July 2016 to June 2017, patients at the trust had higher than expected risks of readmission for both elective and non-elective admissions when compared to the England averages.

The top three specialties in both elective and non-elective admissions have shown a worse performance than the England average, with the exception of respiratory medicine which has a similar performance to the England average. The most noticeably poor performance occurs across the elective admission specialties, indicating a possible capability or capacity issue within this area.

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 is represents the opposite. Top three specialties for specific trust based on count of activity.

Non-Elective Admissions – Trust Level

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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 is represents the opposite. Top three specialties for specific trust based on count of activity.

(Source: HES - Readmissions (01/07/2016 - 30/06/2017))

Sentinel Stroke National Audit Programme (SSNAP) The trust had been identified as an outlier for stroke mortality data. The trust had investigated this and identified an issue with the data submissions for the Sentinel Stroke National Audit Programme (SSNAP). The data submitted was inaccurate and incomplete and had not been signed off by the trust prior to submission. The trust had placed this as a risk on their corporate risk register and recorded mitigations such as:  Data sources for all data fields identified and agreed.  Multidisciplinary team involved with data entry and validation.  SSNAP team visit to be organised for early 2018.

Bradford Royal Infirmary The 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 D in latest audit, which covers the time period from April to June 2017. This was unchanged from the previous quarter, January to March 2017.

The hospital also had an overall team centred score of grade D in both quarters.

Jan-Mar Apr- Team-centred KI levels 17 Jun 17 1) Scanning C C

2) Stroke unit¹ D C

3) Thrombolysis E D

4) Specialist Assessments E D

5) Occupational therapy B B

6) Physiotherapy B B

7) Speech and Language E D therapy 8) MDT working C D

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9) Standards by discharge A B

10) Discharge processes D C

Team-centred SSNAP level D D (after adjustments) Team-centred Total KI level D D

Overall scores Jan-Mar Apr- 17 Jun 17 SSNAP level D D Case ascertainment band A A Audit compliance band B C Combined Total Key Indicator level D D

1 Included in IM reporting, indicator SSNAPD02

Source: Royal College of Physicians London, SSNAP audit)

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Heart Failure Audit In-hospital Care Scores Results for Bradford Teaching Hospitals NHS Foundation Trust in the 2015 Heart Failure Audit were worse than the England and Wales average for all of the four of the standards relating to in- hospital care. In particular, the input from specialist metric was 40% lower than the England average.

Discharge Scores Results for Bradford Teaching Hospitals NHS Foundation Trust results were worse than the England and Wales average for all of the seven standards relating to discharge..

(Source: NICOR - Heart Failure Audit (01/04/2014 - 31/03/2015))

National Diabetes Inpatient Audit

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The National Diabetes Inpatient Audit (NaDIA) measures the quality of diabetes care provided to people with diabetes while they are admitted to hospital whatever the cause, and aims to support quality improvement.

The audit attributes a quartile to each metric which represents how each value compares to the England distribution for that audit year; quartile 1 means that the result is in the lowest 25 per cent, whereas quartile 4 means that the result is in the highest 25 per cent for that audit year.

The 2016 National Diabetes Inpatient Audit identified 105 in patients with diabetes at the trust, 92.2% of which reported that they were satisfied or very satisfied with the overall care of their diabetes while in hospital, which places this site in quartile 4.

(Source: NHS Digital)

Myocardial Ischaemia National Audit Project (MINAP)

All hospitals in England that treat heart attack patients submit data to MINAP by hospital site (as opposed to trust).

From April 2015 to March 2016, 33% of nSTEMI patients were admitted to a cardiac unit or ward at Bradford Royal Infirmary and 98% were seen by a cardiologist or member of the team compared to the England averages of 56% and 96%, respectively.

The proportion of nSTEMI patients who were referred for or had angiography at Bradford Royal Infirmary was 83% compared to an England average of 84%.

nSTEMI patients nSTEMI seen by a patients nSTEMI patients that 2015/16 cardiologist admitted to were referred for or had or a member cardiac unit angiography (incl after of team or ward discharge) Bradford Royal Infirmary 552 552 391 (391) 98% 33% 83% (No data) England: overall 47,039 47,039 39082 (No data) 96% 56% 84% (No data)

(Source: National Institute for Cardiovascular Outcomes Research (NICOR))

Lung Cancer Audit The trust participated in the 2016 Lung Cancer Audit and the proportion of patients seen by a Cancer Nurse Specialist was 32%, which was notably worse the audit aspirational standard of 90% and a considerable drop from the 2015 figure of 96%.

The proportion of patients with histologically confirmed Non-Small Cell Lung Cancer (NSCLC) receiving surgery was 18%; this is not significantly different from the national level. The 2015 figure was 17%

The proportion of fit patients with advanced (NSCLC) receiving chemotherapy was 68%; this is not significantly different from the national level. The 2015 figure was 64%.

The proportion of patients with Small Cell Lung Cancer (SCLC) receiving chemotherapy was

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74%; this is not significantly different from the national level. The 2015 figure was 80%.

The one year relative survival rate for the trust in 2016 was 37% which was not significantly different from the national level.

(Source: National Lung Cancer Audit)

National Audit of Inpatient Falls 2017 The trust had appointed an associate chief nurse for quality improvement in February 2017 and this role led on harm, pressure care and falls prevention. The trust had a multi-disciplinary working group for falls prevention that met monthly and discussed:  Falls data  Falls with harm that had been to an RCA panel  Learning from RCA’s (cross divisional)  Local and national audits  Falls, fragility and fractures  Inpatient falls guidance

The crude proportion of patients who had a vision assessment (if applicable) was 7%; this is below the national aspirational standard of 100%.

The crude proportion of patients who had a lying and standing blood pressure assessment (if applicable) was 11%, this notably below the national aspirational standard of 100%.

The crude proportion of patients assessed for the presence or absence of delirium (if applicable) was 59%, this is below the national aspirational standard of 100%.

The crude proportion of patients with appropriate mobility aid in reach (if applicable) was 62%; this was below the national aspirational standard of 100%.

(Source: Royal College of Physicians)

Competent staff Training that staff needed to undertake their job roles was not consistently up to date. An example of this was the training undertaken for key competencies around the collection, storage and handling of bloods and blood transfusions. Staff based on wards that would handle blood and transfusions more regularly, for example haematology, renal, oncology and dialysis were not all up to date with blood related training and competencies. Staff told us that they received appraisals and found them effective. Some staff felt they had time to reflect on their performance and career within their appraisal. One member of staff we spoke to had progressed in to the nurse associate programme after discussing their career aspirations as part of the appraisal process. We reviewed the appraisal data the trust submitted and this showed that they were not meeting their own target of 100%. Data ranged from 47% - 87%. Allied health professionals had received the most appraisals at 87%, nursing staff at 79% and additional clinical services at 67%. Staff on ward 22 rotated around the three areas of cardiology: the cardiac catheter lab, ward 22 and coronary care unit (CCU). This allowed staff to gain competencies in all areas of cardiology. Student nurses we spoke to felt they had the support and training needed to gain key competencies throughout their ward placements.

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The trust had a clinical education team that provided training and development to staff.

Appraisal rates From October 2016 to September 2017, 78% of staff within medicine at the trust had received an appraisal compared to a trust target of 100%. A split by staff group can be seen in the table below:

Appraisals Appraisals Appraisal Trust Target Staff group completed required rate Target met? Allied Health Professionals 147 148 99% 100% No Nursing & Midwifery registered 337 430 78% 100% No Add Prof Scientific & Technical 7 9 78% 100% No Additional Clinical Services 180 245 73% 100% No Estates & Facilities 5 7 71% 100% No Admin & Clerical 83 129 64% 100% No Healthcare Scientists 8 17 47% 100% No

Bradford Royal Infirmary From October 2016 to September 2017, 73% of staff within medicine at Bradford Royal Infirmary had received an appraisal compared to a trust target of 100%. A split by staff group can be seen below:

Appraisals Appraisals Appraisal Trust Target Staff group completed required rate Target met? Allied Health Professionals 45 52 87% 100% No Nursing & Midwifery registered 282 358 79% 100% No Add Prof Scientific & Technical 7 9 78% 100% No Estates & Facilities 5 7 71% 100% No Additional Clinical Services 126 188 67% 100% No Admin & Clerical 64 106 60% 100% No Healthcare Scientists 8 17 47% 100% No

(Source: Routine Provider Information Request (RPIR) P43 Appraisals)

Multidisciplinary working We observed that the service had an outstanding approach to multidisciplinary working. Staff described effective working relationships between consultants, nurses and allied health professional staff. We observed a safety huddle, board round and handover which incorporated staff from a variety of disciplines. The board round on ward 6, stroke and neurology had a diverse team of staff in attendance. As part of the meeting, they discussed the plans of care and treatment for each patient and made sure that there was a joined up approach in providing treatment. This included referrals to social support and care support once the patient was ready to be discharged from the service. There was evidence of partnership working with the local mental health trust to deliver services for those patients with mental health, drug or alcohol issues. Staff said they worked well with the local mental health trust’s psychiatric liaison team based at Bradford Royal Infirmary. Seven-day services

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There was no input from specialist medical teams at weekends such as respiratory. However the respiratory team had access to an on-call consultant and in reach support from AMU. The trust provided a risk assessment after the inspection around the lack of specialist consultant support at the weekend for the respiratory high dependency unit. Emergency endoscopy was available 24 hours a day to manage gastrointestinal bleeding. Health promotion We observed that during our inspection there were banners for staff and visitors outlining when they had particular symptoms they should stay at home to limit the spread of infections such as flu. We saw that patients with addiction to alcohol and drugs were offered the appropriate medication to relieve withdrawal symptoms and were provided with support from specialist teams. On the wards there was information available for patients to take with them that assisted them in maintaining their own health. We observed that the AMU had leaflets available for patients covering areas such as: alcohol and recognising when you are drinking too much, smoking cessation, falls prevention and how to look after your heart. There were also several health promotion boards on the AMU corridor with information on: diabetes type 1 and 2, alcohol and smoking. On the discharge lounge patients were informed of the ways to maintain their health after discharge. Consent, Mental Capacity Act and Deprivation of Liberty Safeguards The trust had a policy covering the use of the Mental Capacity Act and Deprivation of Liberty Safeguards. Staff had a good understanding of the Mental Capacity Act and Deprivation of Liberty Safeguards. The trust’s safeguarding team were responsible for the delivery of training in the Mental Capacity Act, which also included the use of Deprivation of Liberty Safeguards and making best interests decisions when patients lacked mental capacity. We looked at the course content, which was well detailed and easy to understand. The training was delivered to all staff within the trust. The training was mandatory and was delivered every three years although refresher training was also delivered annually. We were shown a pen that was issued to all staff. Each time the pen was clicked, the pen displayed one of the five principles of the Mental Capacity Act, which meant staff were routinely reminded of what they should consider when considering if a person had mental capacity. The safeguarding team were also responsible for checking that Deprivation of Liberty Safeguards applications were correct. We looked at five applications and noted where the safeguarding team had identified errors, which evidenced that quality assurance measures were effective. We looked at care records for 11 patients with mental ill health. All these records contained details of whether the patient had mental capacity. Staff were able to seek advice about mental capacity, Deprivation of Liberty Safeguards and other issues around mental health from the safeguarding team, the onsite psychiatric liaison and First Response teams provided by the local mental health trust during out of hours.

Mental Capacity Act and Deprivation of Liberty training completion The trust reported that from April 2016 to March 2017 Mental Capacity Act (MCA) training was completed by 94% of medical and dental staff within medicine trust-wide and 94% of staff at Bradford Royal Infirmary. The trust target was 95% completion. The breakdown of course completion by staff group at each location is shown below:

Medical and Dental Staff - Trust wide

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Completion Trust Target Course title Staff trained Staff eligible rate Target met? Mental Capacity Act Level 1 55 57 96% 95% Yes Mental Capacity Act Level 2 53 58 91% 95% No

Medical and Dental Staff – Bradford Royal Infirmary Completion Trust Target Course title Staff trained Staff eligible rate Target met? Mental Capacity Act Level 1 45 46 98% 95% Yes Mental Capacity Act Level 2 43 46 93% 95% No

From April 2016 to March 2017 Mental Capacity Act (MCA) training was completed by 85% of nursing and midwifery staff within medicine trust-wide and 82% at Bradford Royal Infirmary. The breakdown of course completion by staff group for each location is shown below: Nursing Staff - Trust-wide Completion Trust Target Course title Staff trained Staff eligible rate Target met? Mental Capacity Act Level 1 457 527 87% 95% No Mental Capacity Act Level 2 421 507 83% 95% No

Nursing Staff – Bradford Royal Infirmary Completion Trust Target Course title Staff trained Staff eligible rate Target met? Mental Capacity Act Level 1 339 402 84% 95% No Mental Capacity Act Level 2 307 385 80% 95% No

(Source: Routine Provider Information Request (RPIR) P40 – Statutory and Mandatory Training)

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Is the service caring? Compassionate care We observed patients being treated with privacy and dignity. When patients had treatments or nursing care delivered, curtains were pulled round or doors closed. We observed a number of interactions between staff, patients and relatives. Staff were always polite, respectful and professional in their approach. We observed staff mobilising a patients safely and providing them with reassurance and support. Staff were providing patients with clear instructions that they could understand and follow.

Confidentiality was respected in staff discussions with people and those close to them. One patient told us “staff have been superb”. Another patient told us that the staff were “very caring and compassionate”.

We spoke with three patients in the discharge lounge and they were all positive about their time in hospital describing it as “a good experience”. Two patients told us that particular members of staff had gone above and beyond to ensure they were well cared for during their time on the wards they were on.

We observed that many of the wards we visited had received thank you cards from patients and relatives, thanking staff for the support and treatment they had received. Friends and Family test performance The Friends and Family Test overall response rate for medicine at the trust was 12% which was worse than the England average of 25% from October 2016 to September 2017.

At the time of the inspection we reviewed the latest Friends and Family Test data for Bradford Royal Infirmary only and the response rate was 17.5%, this was still however still under the England average of 25%. The data showed 94% of respondents would recommend Bradford Royal Infirmary.

Friends and family Test – Response rate from October 2016 to September 2017 by site

A breakdown of FFT performance by ward for medical wards at the trust with total responses over 100 is below. All the wards had annual recommendation rates above 90%.

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Highest score to Lowest score Key 100% 50% 0%

Note - 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.

Note: sorted by total response

(Source: NHS England Friends and Family Test)

NHS Inpatient Survey Results The trust participated in the 2016 adult inpatient survey, the results below relate to some questions that reflect our caring domain. The results are at trust level and include all adult inpatients, from both medicine and surgery. Results show the trust is rated ‘about the same’ as other trusts in 10 questions, and ‘worse than’ other trusts in one question.

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(Source: CQC website survey data for Bradford Teaching Hospitals Trust) Emotional support Staff provided emotional support to patients to minimise their distress. Patients reported that if they became upset or distressed, staff were quick to respond and give reassurance.

The trust had a multi-faith chaplaincy team who visited wards on a weekly basis, offering confidential support to all patients and staff with a faith and those with none. The chaplaincy service was available Monday to Friday from 8am - 4pm. The chaplaincy team consisted of seven male and female chaplains from the Muslim, Christian, Sikh and Hindu faiths. This provided a service representative of the local culturally diverse population. There was a prayer room located on level 1 at Bradford Royal Infirmary. Understanding and involvement of patients and those close to them Patients told us staff explained their care and treatment to them in a way they could understand. One patient told us that they felt supported to have input in to their care plan as part of a two way dialogue. We observed staff communicating in a way that people could understand and was appropriate and respectful. Patients and relatives told us they were kept informed of what was happening and understood what tests or treatment they were waiting for. However one patient told us they had been moved around various beds on the ward often at short notice, without appropriate questions being asked about their pain levels or readiness to move. Another patient told us that they felt supported to have input in to their care and was updated regularly on this, with the exception of discussions around their discharge and they were anxious to get home. Is the service responsive?

Service delivery to meet the needs of local people The environment throughout the service was not sufficiently adapted to provide people with care in a way that met their needs. However the service had plans to adapt the environment to be more person-centred, this was in its early stages at the time of our inspection. The trust was undertaking a large relocation and refurbishment project that would see some wards move in to more suitable premises which would improve the environment care was delivered in and make it more patient centred. Wards that required en-suite facilities would move to wards that provided these facilities. Throughout the service the signage was confusing. This made navigating throughout the service and between different wards difficult at times. For a patient with a cognitive impairment navigating the hospital may be confusing. Ward 24 infectious diseases and ward 19 discharge lounge proved difficult to find during our inspection. The divisional leadership team had a good understanding of the local demographic and their health needs. They understood the local health landscape and were passionate about the integration of the virtual ward in to the service and working with community partnerships. The service collaborated with partner organisations effectively, including a local dementia charity that worked with people from a South Asian background which represents a high proportion of the local demographic. The chaplaincy team consisted of seven male and female chaplains from the Muslim, Christian, Sikh and Hindu faiths. This provided a service representative of the local culturally diverse population. The service was part of the Bradford Breathing Better programme of work to improve respiratory health services for local people and reducing avoidable hospital admissions.

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The divisional leadership team told us that the division took part in frequent attenders meetings in partnership with organisations such as the police, local mental health providers, community drug and alcohol services and social care. This meant they could plan services for frequent attenders and manage their care and treatment in a joined up and coordinated approach. Average length of stay Average Length of Stay by Specialty - Medicine By discharge month, emergency admissions only

2017/18 2017/18 2017/18

Oct Nov Dec

Cardiology 4.3 5.8 4.6

Clinical Haematology 15.2 10.9 6.9

Diabetic Medicine 5.6 1.0 1.3

Endocrinology 4.2 2.4 3.7

General Medicine 2.3 3.1 3.4

Geriatric Medicine 6.9 7.8 7.0

Infectious Diseases 6.4 2.4 1.5

Medical Oncology 4.4 3.6 4.6

Nephrology 20.6 6.5 4.2

Neurology 7.5 2.7 5.9

Respiratory Medicine 4.3 10.4 6.0

Stroke Medicine 1.0 5.4 6.2 Transient Ischaemic Attack 7.5 15.8 33.5 (Source: data request MED 15 MED15 20180115_Avg_LOS_by_Spec_Medicine_Emerg (4))

Trust Level From August 2016 to July 2017 the average length of stay for medical elective patients at the trust was 3.2 days, which is lower than the England average of 4.2 days.

For medical non-elective patients, the average length of stay was 3.9 days, which is lower than the England average of 6.6 days.

The most notable performance is for the non-elective specialties. Geriatric Medicine stays are less than half the England average, with General Medicine and Respiratory Medicine almost achieving this, being just over half of the England averages in both cases.

The gap in the elective specialties is less pronounced, but for both overall length of stay and the Gastroenterology specialty the trust beats the England average by around a day.

Elective Average Length of Stay – Trust Level

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

Non-Elective Average Length of Stay – Trust Level

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

(Source: Hospital Episode Statistics)

Meeting people’s individual needs The wards had dementia friendly signs, these included signs for the toilets. Toilet doors were yellow and easily identifiable for patients and visitors with dementia. The volunteers working in the hospital had all undertaken dementia training and were dementia friends. We saw that signs on entrance to the wards were in different languages to welcome patients and relatives onto the wards. There was also signage in different languages at the reception on the main hospital concourse. Staff told us that they could access interpreter services for patients and if there was a member of staff within the team that spoke that language they could also use them. Staff would not use family members for interpretation which is in line with best practice. We saw on ward 29 and 31 there were various activities available for patient. These ranged from jigsaws, papers and dominoes. Memory boxes were around the ward including old style radios and postcards and pictures of seaside holiday resorts. Ward 29 had a room styled as a café/coffee shop for patients to use. Staff were able to give us examples of when they had treated patients with learning disabilities. They told us that they would speak to the patient and their carer to build a picture of their likes and dislikes and utilise any other resources, for example a hospital ‘passport’ or ‘this is me’ document to ensure that their stay in hospital was as stress free as possible. Effective working relationships within teams and external services meant the needs of patients with mental ill health were being met. We looked at the progress of one patient who came to the department with sepsis and affected pseudo aneurysm as a result of intravenous drug misuse being quickly assessed by the psychiatric liaison team who diagnosed them with severe psychosis. The patient, was currently under the care of a local mental health hospital, was admitted to a ward under section 3 of the Mental Health Act. The senior sister on the ward told us that they were able to clear rooms when the patient became at their most heightened. Advice was

20171116 900885 Post-inspection Evidence appendix template v3 Page 116 also sought from a mental health nurse who worked in the trust’s safeguarding team about de- escalation techniques which included talking with them or playing music. An agreement between the trust and the local mental health trust was met so the patient could stay on the ward for a further three weeks due to concerns about their physical health. On the day of our inspection, the patient was due to be discharged and admitted back to a local mental health hospital. Access and flow The service was managing access and flow very well during a particularly difficult period due to winter pressures. There were specific escalation beds across the hospital that were opened as needed due to additional bed pressures. One matron had responsibility for medical outliers. A medical outlier is a patient who is cared for in a non-speciality bed, which may not be best suited to meet their needs. However, the trust managed medical outliers well. This involved ensuring that all patients received a review within the day and were managed by the medical team allocated to the outliers. At the time of our inspection there were 50 medical outliers. This had reduced from previous days. On ward 22, the ward contained 6 surge beds that were located at the end of the ward. These were used as overflow beds and were full at the time of inspection. We visited the cardiology catherisation laboratory; staff told us that there were no long waits for investigations. Waiting list and RTT data for angiograms, angioplasty, pacemakers and cardioversions in October, November and December showed that the service had not always seen patients within 18 weeks. Extra lists had been provided for certain investigations. There had been no cancellations for non-clinical reasons. Waiting list and RTT data for angiograms, angioplasty, pacemakers and cardioversions:

Sep-17 Oct-17 Nov-17 Sep Oct Nov TREATMENT FUNCTION NHS CODE <18 >18 Total <18 >18 Total <18 >18 Total <18 % <18 % <18 % DESC CARDIOLOGY 12 6 18 41 6 47 50 9 59 66.70% 87.20% 84.70%

(Source: MED21 Cardiology data request) The virtual ward service provided integrated, multidisciplinary care, aimed at avoiding unnecessary admissions and readmissions to hospital, and promoting and supporting earlier discharge from hospital. It was managed within the division of medicine and integrated care.

A team of clinical staff, (nursing, therapy and medical) provided responsive assessment, monitoring, investigations, support and education which:  Provided an alternative pathway for those patients who did not require acute medical in- patient but did require intensive therapy and/or nursing care  Facilitated early supported discharge from hospital to help people leave hospital earlier than would have traditionally been possible  Prevented an admission to acute care or permanent residential care

Divisional bronze meetings were held daily and attended by the head of nursing, matrons, social services and the discharge team. They reviewed the availability of beds and identified reasons why certain patients were not appropriate to attend the discharge lounge. Medical patients that were placed on non-medical wards were also discussed to identify if they were appropriately managed and could be replaced on a medical ward. The service had a renewed focus on avoiding night-time transfers after 10pm. Improvement was enabled by the work undertaken by the department on patient flow. The Chief Operating Officer had oversight of the work stream.

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Referral to treatment (percentage within 18 weeks) - admitted performance The performance of the trust was slightly better than the England average from October 2016 to March 2017; the trust then dipped slightly below in April 2017 and showed a minor degree of fluctuation, always around the England average until August 2017. No data was submitted for September 2017.

(Source: NHS England)

Referral to treatment (percentage within 18 weeks) – by specialty Three specialties were above the England average for admitted RTT (percentage within 18 weeks).

Specialty grouping Result England average Geriatric Medicine 100% 100% Neurology 100% 92.0% Thoracic Medicine 100% 93.7%

One specialty was below the England average for admitted RTT (percentage within 18 weeks). This is a notably weaker result than the other three specialities, falling 25% below their performance. Rheumatology falls 18.5% below the England average.

Specialty grouping Result England average Rheumatology 75% 93.5%

(Source: NHS England) Learning from complaints and concerns Summary of complaints From October 2016 to September 2017 there were 103 trust wide complaints about medical care. The trust took an average of 64 days to investigate and close complaints; this is not in line with their complaints policy, which states complaints should be resolved within 30 days of receipt. The most common cause of complaint was recorded as ‘aspects of clinical treatment’ with 49 complaints, staff attitude being the next most common with 18 complaints. The trust had acknowledged that there were historical issues with response times to complaints and this was reflected as a risk on the corporate risk register. The chart below shows a summary of the number of complaints in 2015/16 vs. 2016/17. The figures below relate to the whole division of medicine and integrated care and are not broken down for solely medical complaints as detailed above.

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(Source: P101 Bo.6.17.12 - Complaints and Patient Advice Liaison Annual Report)

Bradford Royal Infirmary There were 92 complaints which took an average of 64 days to investigate and close. 46 complaints related to ‘aspects of clinical treatment’ and 17 complaints to staff attitude. (Source: Routine Provider Information Request (RPIR) P61 Complaints)

Learning from complaints and concerns Staff told us that initial complaints were managed locally on the ward they occurred on, this is in line with trust policy. If the complaint could not be resolved locally then staff told us they would escalate to their manager. However, staff were keen to try and resolve complaints before they reached that stage. Complaints and concerns were discussed at the daily ‘matron huddle’ and the head of nursing could allocate a matron to investigate further if necessary. In the 2016 NHS adult inpatient survey the trust scored ‘about the same’ as other trusts in relation to seeing or being given information about how to complain.

(Source: CQC website survey data for Bradford Teaching Hospitals Trust) 20171116 900885 Post-inspection Evidence appendix template v3 Page 119

Details of how to raise a concern or make a complaint was detailed on the trust website. Complaints, concerns and comments could be made via the Patient Advocacy and Liaison Service (PALS) or in person to the ward sister, matron or nurse in charge. If complainants were unhappy with the response or felt their complaint had not been resolved, they could raise a formal complaint with the chief executive officer, via the complaints team, within 12 months of the initial complaint. The trust outlined the complaints process on their website: When you make a complaint we will –  Acknowledge receipt of your complaint letter within three working days;  Allocate a Complaint Investigator who will contact you to give you the opportunity to discuss your complaint and the way you would like it to be investigated;  If your complaint can be resolved informally and to your satisfaction the Complaint investigator will discuss this with you;  Provide a full written response within five weeks (25 working days) from receipt of your complaint, wherever possible;  Keep you informed if we need more time to investigate complex issues or/and agree an extended response time;  Learn from your complaint and make changes in the way we provide our services when necessary. The trust reviewed complaints annually using a ‘complaints and patient advice liaison annual report’ presented by the chief nurse. The report presented complaints by division and speciality, highlighting key themes and trends to use as a learning tool.

Is the service well-led?

Leadership The division of medicine and integrated care was split in to five directorates as shown in the below diagram:

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(Source – Routine Provider Information Request (RPIR) P112 Division of Medicine and Integrated Care) A triumvirate of a divisional clinical director, a divisional general manager and a divisional head of nursing led the division of integrated medicine. Ward areas had a matron and nurse in charge (ward manager). Matrons provided strategic and managerial support for the wards under their responsibility. This structure provided direct nursing and medical leadership. The nursing and medical team was established with experienced staff that provided clinical and professional leadership by supporting and appraising junior staff. Junior staff told us that they were well supported in their roles and had a clear understanding of their responsibilities. They said leaders were visible and approachable. Staff told us that senior managers were aware of the local challenges the division faced. The divisional managers knew about the quality issues, priorities and challenges the division faced and worked collaboratively site-wide to try and deliver solutions and pilot new ways of working. We observed that managers were proactive and their positivity and motivation was inspiring. The divisional leadership team demonstrated a clear approach to assessing and managing patient flow and safety within the division of medicine and integrated care. The head of nursing led a ‘matron huddle’ every morning and they discussed staffing, complex care cases, outliers, patient flow issues, complaints and serious incidents. Actions were agreed and acted on rapidly, with the head of nursing following up actions and outcomes from the previous day in the meeting. There was a clear commitment and focus by leaders to predict and respond to patient demand and flow issues within the division of medicine and integrated care, and this was clearly supported by the other departments in the hospital, particularly around the management of medical outliers on surgical wards. Vision and strategy The trust had a clear vision and strategy that was quality driven and focused on values. The trust had produced a booklet called ‘We are Bradford’ that detailed the vision, values, strategic objectives, the clinical service strategy for 2017 – 2022, how the trust is managed and the trust mission.

(Source: MED18 BTH We Are Bradford Booklet.pdf) Senior leaders told us that the ward areas were looking at how they could evolve. Ward areas had contributed to the annual plan. The annual plan fed in to the performance and business plan for

20171116 900885 Post-inspection Evidence appendix template v3 Page 121 the trust. Ward areas had mapped a ‘wish list’ of what they would like to evolve and deliver and this had been prioritised in order of the deliverables that could be acted on first. The divisional leadership team told us about a series of upcoming ward moves that were part of a strategy to provide a better service to patients. There were plans to relocate wards within the current estates footprint, to ensure that the environment and facilities better suited the acuity of the patients and the specialism of the ward. We saw that the trust had made progress around the previous vision and strategy. At the last inspection the trust had plans to expand the hyper acute stroke unit (HASU) to six beds and relocate the stroke ward on to ward 6 to provide a more suitable environment. We saw on our latest inspection this work had been completed and the ward provided six HASU beds and a combined stroke and rehabilitation ward. The trust had a vision for renal services, involving patients in the co-production and planning of a new renal satellite unit and promoting and supporting patients with self-care. The trust also had a strong vision for elderly services, having implemented a ‘virtual ward’ and with plans to explore the possibility of implementing a day hospital to avoid elderly admissions. The division of medicine and integrated care already utilised the ‘virtual ward’ for elderly discharges to support patients to receive appropriate care in their own homes and provide ‘wrap-around’ care to these patients. The trust recognised the importance of workforce planning to ensure a consistent and effective service. The divisional leadership had looked at alternative roles that could be used to strengthen the workforce and lessen the pressures around nursing staff shortages. The service employed:  Advanced nurse practitioners (ANP’s)  Advanced clinical practitioners (ACP’s) from physiotherapy and paramedic disciplines  A physicians associate  Nurse associates The leadership team told us that the new roles had assisted the trust with the retention of staff, as some staff had been able to progress in to the new roles, such as the nurse associate role. Culture We found the culture of the division of medicine and integrated care to be open and inclusive. Staff that we spoke with felt that they were valued and respected by their peers and leaders. Many of the staff we spoke to had worked for the trust for a number of years. We asked staff about morale and were told morale was predominantly good and staff worked collaboratively as a team, however morale was lower in some areas due to the amount of nurse vacancies. Staff felt there were still some pressures around staffing, however they were proud to work at the hospital. Staff felt supported in their work and there were opportunities to develop their skills and competencies, which was encouraged by senior staff. We spoke to a nurse associate who told us that they had been given the opportunity to progress and develop from the role of healthcare assistant and that peers, managers and medical staff had been very enthusiastic and supportive. Staff also felt that they could raise ideas that could be piloted on wards and they would be taken seriously and their ideas considered by the management team. Staff we spoke with wanted to provide effective care and treatment to patients and put patients at the centre of the experience. We observed staff working well together and there were positive working relationships within the multidisciplinary teams. The leadership team told us there had been a fundamental shift to empower teams to deliver, as experts, at a local level. Allied health professionals were particularly well embedded across the division and took part in the multidisciplinary team meetings on the wards they worked on. Staff at all levels also told us that Bradford Royal Infirmary was ‘a lovely place to work’ and it captured ‘the essence of Bradford’. Governance

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The service was committed to improving services by learning from when things go well and when they go wrong, promoting training, research and innovation. There were five directorates within the division of medicine and integrated care. There was a divisional leadership team comprising of the clinical director, a general manager and a head of nursing. There was clear accountability and objectives for the division that were set by the executive team and the board. At all levels of management there were clinicians to support the strategic and operational delivery of services. The divisional leadership team told us that ward areas regularly presented findings of ‘deep dive’ exercises to the executive team, so the executive team were well sighted on local issues and had ‘ward to board’ communication. The leadership team told us they were keen to empower local teams to deliver as experts in their respective areas. The service had an associate chief nurse for quality improvement who reported in to the chief nurse. This role contributed to the governance and quality improvement measures in the division. The service had a ward assessment accreditation system and a standard operating procedure (SOP). This covered a number of areas including nutrition, tissue viability, falls, medicines, pain management, patient experience, safeguarding and leadership. Wards were inspected and graded red, amber or green with key lines of enquiry linked the CQC domains and the 6 C’s. Action plans were put in place as appropriate. Ward managers said that this had improved patient safety on the wards. Management of risk, issues and performance There was a departmental risk register, which measured the impact and likelihood of the risk and documented the controls and mitigations in place to manage the risk. This fed in to the corporate risk register so that the board were sighted on local risks. Divisional bronze meetings were held daily and attended by the head of nursing, matrons, social services and the discharge team. They reviewed the availability of beds and identified reasons why certain patients were not appropriate to attend the discharge lounge. Medical patients that were placed on non-medical wards were also discussed to identify if they were appropriately managed and could be replaced on a medical ward. The trust had devised a contingency plan that would have required bed spaces in the cardiology catheter laboratory to be utilised. Information management Staff were able to access patient information using an electronic patient record system. The system was relatively new and still being embedded in the trust. Every member of staff we spoke to was positive and engaged with the electronic patient record system. The divisional leadership team told us that the trust had embarked on a large piece of engagement work with all staff, ensuring that staff were familiar with the system and allowing the smooth roll out and embedding of the system in practice. Staff told us that the system worked well and there were no issues with internet access. We observed good practice in relation to information security. Staff locked their computers and did not leave records open and unattended on screen. However the location of some of the computers, for example in AMU ward 4, was close to some of the patient beds and the monitors did not appear to be fitted with privacy screens.

Engagement

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The service engaged well with patients, staff, the public and local organisations to plan and manage appropriate services. The service collaborated with partner organisations effectively, particularly around dementia care where the trust engaged with several local voluntary sector organisations, including a local dementia charity that worked with people from a South Asian background which represents a high proportion of the local demographic. The infection prevention and control team worked as part of a local network with other providers to share ideas and provide a consistent approach to infection control across the district. There were display boards highlighting relevant information such as when to stay away from the hospital to control the spread of winter infections. These featured key members of the management team in order to identify them to staff and public. Staff on ward 22 told us that secondary double glazing had been added to the windows as both patients and staff had complained about how the ward was too cold. Some wards had volunteers that would attend on a regular basis. Volunteers would ask patients specific questions about their experience and document this on an iPad. The trust’s website outlined opportunities to contact the trust and express opinions. It also supplied information on the services and hospital. The trust utilised social media as an engagement tool with the public and a list of social media accounts was listed on the website. The trust conducted an annual staff survey, results for the division of medicine from the 2016 staff survey showed there were 87 respondents. There was an increase in engagement for the division but this was not the same at trust level. Response rates to the friends and family test in medicine during November 2017 were 17.5% which was worse than the England average of 25.5%; however 94% of respondents would be likely to recommend the trust. The trust also took part in the national NHS inpatients survey in 2016 (results for 2017 are published later in 2018). This survey looked at the experiences of 77,850 people who received care at an NHS hospital in July 2016. Between August 2016 and January 2017, a questionnaire was sent to 1,250 recent inpatients at each trust. Responses were received from 398 patients at Bradford Teaching Hospitals NHS Foundation Trust. The trust scored ‘about the same’ as other trusts in the majority of questions. Learning, continuous improvement and innovation The trust had an award winning ‘virtual ward’ model. The aim of the virtual ward hub development was to offer a single point of assessment, to offer a range of ‘wrap around’ support at home and to ensure that the frail older person gets the right service at the right time. The service comprised of a hub of multidisciplinary staff, led by a geriatric medicine consultant and a nurse consultant, supported by various multidisciplinary staff including advanced nurse practitioners (ANP’s), nurses and therapy staff from disciplines including dietetics, physiotherapy and occupational therapy. The model had improved ‘cross boundary’ working and had a significant impact on the length of stay for elderly patients and avoided some hospital admissions entirely. The virtual ward focussed on a ‘home first’ model, allowing patients to be cared for in their own homes by specialised staff. The trust had won a HSJ value in healthcare award. The judges said it was an excellent example of a highly functioning integrated health and social care service. Therapies had been embedded in the division approximately 12 months ago. The divisional leadership team told us that this had ensured that therapy was integrated as part of the division of medicine and integrated care and we saw that therapy staff were a key part of teams on our inspection. Multidisciplinary working was well embedded and staff we spoke to told us that bringing therapy over to the division of medicine and integrated care had strengthened multidisciplinary working.

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The trust had a dementia strategy framework and a dementia strategy action plan covering 2017 – 2020. The lead nurse for dementia was undertaking an innovative pilot on the prevention of delirium across several wards in 2018. The lead nurse for dementia provided inspiring leadership for embedding and rolling out the dementia strategy framework 2017 - 2020. The trust had secured funding and purchased ‘my life’ units that would be rolled out to other areas after they had been successful on the elderly care units for patients with dementia. The trust had an innovative project allowing local college students studying health and health related subjects, to work in the community hospital with elderly patients. They offered a supportive ‘befriending’ type service and in return could gain experience of working in real health care setting and use the experience for university or job applications. The divisional leadership team told us the palliative care team had won a national award. We were shown a pen that was issued to all staff. Each time the pen was clicked, the pen displayed one of the five principles of the Mental Capacity Act, which meant staff were routinely reminded of what they should consider when considering if a person had mental capacity. As part of a teaching hospitals trust, the division had a strong research and academic focus. The trust received research grants from Bradford Institute for Health Research (BIHR) enabling the division to undertake some unique and pioneering research. The division had some academics working as clinicians on shifts. The trust had also undertaken innovative research to analyse variances in clinicians practice. This was a risk-based research project, looking at patient outcomes. It found that clinicians who make ‘riskier’ decisions had the same patient outcomes as more risk adverse clinicians. The trust were looking at introducing new roles such as pharmacy technicians, their role would primarily involve working alongside the nursing staff to administer medication. The trust had taken part in a project with community partners, offering apprenticeships to members of the community with a learning disability. The project had been successful and many of the apprentices had gained permanent employment within the hospital. The associate chief nurse for quality improvement ran monthly ‘back to basics’ sessions, which encouraged staff to reflect and learn from a variety of sources to feed in to quality improvement initiatives. These sessions covered a wide variety of topics and included learning from the outcomes of RCA panels, complaints, incidents and changes in national guidance. The sessions had become more popular and staff were in regular attendance.

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Surgery

Facts and data about this service The trust has five main operating theatres and ten surgical wards. The Division provides and delivers acute, elective and day case surgery within four Directorates: The Digestive Diseases, Urology and Vascular Surgery Directorate; the Theatres & Critical Care Directorate; the Orthopaedics, Plastics & Breast Directorate; and the Head and Neck Directorate.

(Source: Trust website)

The Division of Surgery, Anaesthesia and diagnostics runs elective services across five hospital sites in the city of Bradford: Bradford Royal Infirmary; St Luke’s Hospital; Eccleshill Hospital, Westwood Park Hospital and Shipley Hospital.

The division has the following theatres; Modular Theatres 1-4, Theatres 5-8, Nucleus Theatres 1- 4 and ENT Theatres.

The division is a Specialist Centre for Upper GI Cancer, Urology (including robotic surgery) and Head and Neck Cancer. Bradford Teaching Hospitals NHS Foundation Trust hosts the Yorkshire Cochlear Implant Centre and the surgical division provides services to neighbouring Trusts in Ophthalmology, ENT, Plastics, Maxillo Facial and Acute Vascular Services.

The trust has 233 inpatient beds with an additional six assessment trolleys.

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

The trust had 38,405 surgical admissions from August 2016 to July 2017. Emergency admissions accounted for 16,267 cases (42%), 15,793 (41%) were day cases, and the remaining 6,345 (17%) were elective.

(Source: Hospital Episode Statistics)

During this inspection we visited surgical wards 5 (general surgery), 8 (general surgery, male), 11 (general surgery, female), 12 (gynaecological), 14 (urology), 18 (head and neck, progressive care unit), 20 (surgical assessment unit), 25 (gastroenterology), 26 (vascular), 27 (orthopaedics, plastics and trauma) and 28 (elective orthopaedic and breast surgery). We spoke with 56 patients and relatives and 63 members of staff. We observed care and treatment and looked at 29 care records. We reviewed trust policies and performance information from, and about, the trust. We received comments from patients and members of the public who contacted us directly to tell us about their experiences. 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 trust had systems and processes in place to ensure staff were trained in mandatory training and staff we spoke with confirmed that they had enough time to complete mandatory training. The trust set a trust target of 95% completion for most mandatory training modules and 75% for

20171116 900885 Post-inspection Evidence appendix template v3 Page 126 some specialist modules, such as Dangers of Misplaced Naso Gastric (NG) Tube.

At the last inspection the percentage completion rates for mandatory training were variable across different directorates within the division. The latest data shows varied compliance across staff groups and modules. The lowest compliance is in adult basic life support, safe administration of medicines, and infection control. In spite of this we found infection control and medicine administration was good.

We looked at a sample of modules as follows. The position is stated as at March 2017 and (unless otherwise shown) the percentage compliance rates are shown in brackets for nursing and then medical staffing.

 Adult basic life support (annual) - 62% and 53%;  Dangers of misplaced nasogastric tube (annual) - medical staff only 100%;  Diabetes care and safe use of insulin (annual) - 89% and 95%;  Fire safety (every one or two years) - 77%) and 84%;  Infection control (annual) - 61%) and 68%;  Information governance (annual) - 73% and 81%;  Mental capacity act level 1 (annual) - 99% and 100%, level 2 (annual) - 91% and 96%;  Safe administration of medicines (biannual) - nurses only, 75%  Safe administration and preparation of injections (annual) - medical staff only, 95%; and  Venous thromboembolism (annual) - nurses only, 87%.

The trust explained that completion of mandatory training was suspended because of the phased introduction of the new electronic patient record. This occurred in September 2017, and so senior staff said it would take time for staff to catch up with their mandatory training.

At ward level senior staff told us that their staff were booked on to receive training and staff we spoke with confirmed that training completion was something discussed at annual appraisals and throughout the year. Safeguarding Safeguarding training completion rates

The trust had systems and processes in place to protect patients from abuse and staff had been trained in and were aware of safeguarding and how to get help so that safeguarding was everyone’s responsibility.

We saw that the trust had an up to date safeguarding policy that staff accessed on the trust’s intranet. This had been prepared in discussion with interested third party stakeholders.

The trust had a lead nurse for adult and children safeguarding. The safeguarding sub-group reported to the safety and quality committee which reported to the board.

When we asked staff about safeguarding they were able to describe circumstances when they had made a safeguarding referral with the help of the central safeguarding team. A total of 692 safeguarding referrals were made in the period April 2016 to March 2017, which was a decrease on the previous year’s figure which was 1090. The trust believes the drop in reporting was explained by the fact that pressure ulcers not involving neglect were now reported to a different team.

The electronic patient record allowed staff to track children within the division and staff were able to identify children subject to a child protection plan. In the last 12 months only 2% of admissions to the surgery division were children. Staff explained that if children were present on an adult ward they permitted parents to stay with them.

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The training levels for safeguarding had improved since the last inspection. Staff were required to have training in safeguarding adults level 1 and 2 and for children levels 1, 2 and 3. As at March 2017 nursing staff were 92% compliant with adults 1 and 82% for 2, with medical staff 83% and 43% respectively. For children, nursing and medical staff respectively, the percentages were: 94% and 93% (level1); 91% and 86% (level 2); and 100% and 67% (level 3). Both courses ran every three years. The mandatory training included training on PREVENT, female genital mutilation and child sexual exploitation.

Staff at ward level described good support from the psychiatric liaison team for patients with mental health needs.

Cleanliness, infection control and hygiene We found all ward areas and theatres were visibly clean and tidy and the trust had systems and processes in place to monitor and eliminate the risk of infection.

All patients were screened for healthcare acquired infections. Elements to assess patients who were at risk of developing a healthcare infection were incorporated into the nursing assessment documentation as part of the electronic patient record (EPR). For 2016/17 there were 6 cases trust-wide of methicillin-resistant staphylococcus aureus (MRSA) against a target of zero, with four of these cases attributable to the surgery division. Post infection reviews were conducted so that lessons were learned. No trends were identified by the trust. There was a total of 30 trust attributed cases (inpatients diagnosed on day 3 or more of admission) in 2016-17 for clostridium difficile (C difficile) which was below the target of 51. Over the past ten years there has been a downward trend.

All wards performed a suite of 15 audits ranging from hand hygiene to central venous catheter care insertion and care. The trust looked for 95% compliance and audit results for April 2016 to March 2017 showed this was achieved in 11 out of 15 of the audits. In relation to the 4 audits where the target was not met, it was met in February/March 2017 apart from in high and low risk methicillin-resistant staphylococcus aureus (MRSA) screening and patients with diarrhoea.

The central trust infection prevention control team reported results of audits of cleaning standards and spot checks to clinical areas and on the infection control dashboard to ensure that any deficiencies detected were corrected and they monitored progress.

The trust told us hydrogen peroxide vapour (HPV) decontamination of all single rooms vacated by a patient with highly resistant bacteria (CPE) or clostridium difficile (C difficile) was carried out. Checks of thoroughness of infection cleaning using swabs were used to ensure continued high standards of cleaning were maintained.

Results from the 2016 quarter one mandatory surgical site infection (SSI) surveillance for hip replacement and knee replacement surgery showed the division (for infections observed during admission and for 30 days after the operation) was better than the national average for hip (0.8%) and knee (0.4%).

Staff were seen to be ‘bare below the elbow’ and made use of hand alcohol gels and personal protective equipment. We saw there were alcohol hand gels available on entry into the ward and posters on hand washing and there were sinks available with adequate supplies of soap and paper towels. We saw that patients requiring isolation were in separate rooms with barrier nursing signage on the doors.

We saw the sluice and linen room on each ward were clean and tidy and all commodes seen were clean and had ‘I am clean’ stickers on them. 20171116 900885 Post-inspection Evidence appendix template v3 Page 128

Unlike the previous inspection, where staff reported problems accessing isolation rooms, we found that wards had rooms available to isolate patients with signage on the doors to indicate the level of barrier nursing required. According to the infection control annual report 2016/17 availability of side rooms was monitored using the side room daily report and where rooms were not available, patients were individually risk assessed by the infection prevention control team.

In theatres we did find blood splattered footwear in a changing room which we reported to the trust but otherwise theatres and adjoining areas used by theatres were clean and tidy.

We saw that waste was segregated using colour coded bins into clinical and non-clinical waste. Domestic staff doing the cleaning used colour coded mops and buckets and worked to a pre- populated cleaning schedule. Substances hazardous to health were stored behind locked doors.

Environment and equipment We found the ward was accessible to wheelchair users, with clear signage, and access restricted by buzzers, although in theatres there were issues with flooring in some of the theatres. We saw that there was enough equipment for staff to use which was maintained and ready for use. Toilets for use by staff and visitors were clean and wheelchair accessible.

Many of the wards we visited had individual patient rooms with doors or doors leading to patient bays separated by curtains but two of the wards were open plan with beds separated by curtains. Patients we spoke with on these wards mentioned dis-satisfaction with noise and lighting being left on until midnight. Staff handed out ear plugs to address the noise issues but explained that lighting was needed when providing patient care. Fortunately, patients on these wards were in hospital for a short stay.

In the theatres environment the flooring in some of the theatres was cracked and therefore unsafe. While the trust were aware of this and had done interim repairs, before we left, the theatres affected by the flooring issue were closed. The trust later told us that they had undertaken the required initial work in ENT theatres 1 and 2 and they were now being used again and that the floors would be covered as soon as is possible. Following inspection we received the trust’s risk assessment which concluded that ‘…there has been no evidence from report incidents or clinical feedback or routine IPC observational audits that cross contamination have occurred’. We raised the risk of contamination of the clean scrub area during the movement of dirty instruments from theatre due to the current direction of flow through a clean area not directly into a demarcated dirty area. The trust provided us with their risk assessment of this issue which concluded ‘…there has been no evidence from report incidents or clinical feedback or routine IPC observational audits that cross contamination has occurred’ and ‘…following clinical discussion and evaluation whilst the risk is minimal we cannot eradicate the risk completely and therefore the risk level remains…’

As in the previous inspection we visited the operating theatre at the end of ward 14 but it was not in use during our inspection and so we were unable to assess its use.

Staff we spoke with reported that they had enough equipment to provide safe care to patients. We saw staff making use of personal protective equipment, for instance, when barrier nursing a patient.

We checked resuscitation trolleys on each ward we visited and in the theatre environment and found that daily checks had been completed.

All sharps bins seen were properly assembled; stored off of the floor; not over full and signed and dated.

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The trust told us that all equipment within the trust is subject to routine planned preventative maintenance as defined by the equipment manufacturer. We saw that equipment on the wards had asset register stickers on them, had been maintained, and were safety checked.

There were no mental health act section 136 places of safety within trust property. The nearest place of safety was at a local trust. Assessing and responding to patient risk We saw that the division had systems and processes in place to support staff in wards and theatres to assess and respond to patient risk. For example, on occasions when critical care patients were nursed in recovery areas within theatres, specialist critical care nurses were available.

Within the electronic patient record there were a series of prompts built in to support staff in managing risks posed to individual patients. For example, automatic drug alerts, dose alerts, allergy alerts, venous thromboembolism alerts and care bundles such as for pressure ulcers or falls.

Information gathered from the electronic patient record was used to help the trust assess and respond to patient risks. For instance, three wards in the division were identified as high falls risk areas. All three wards were involved in a mini collaborative using the rapid improvement approach to identify the underlying causes of patient falls with harm. All patients that had suffered harm had a root cause analysis completed and were monitored through the falls prevention group. We saw from viewing handover notes that falls risks were discussed. The trust told us the matron visited every patient who had reported a fall to look at the underlying cause and that learning from the work around falls was shared regularly between matrons and fed back to staff.

Staff, using the electronic patient record, recorded patient observations using the NEWS score. In addition, we saw that each ward displayed posters about the risk of sepsis. All staff we spoke with were able to describe what they would do to help tackle sepsis. For example, they all mentioned the ‘BUFALO’ acronym (which helps clinicians to remember the elements of the sepsis 6 care bundle) which helped them to identify when to put a patient on a sepsis pathway. Staff also had access to an outreach team if NEWS scores were abnormal and staff required additional help.

In theatres staff used the World Health Organisation’ (WHO) surgical safety checklist. At the last inspection we found use of the checklist did not appear to be embedded. At this inspection we saw that audits were completed for all theatres on a monthly basis. Staff told us the audit identified whether the sign-in, time-out and sign-out had been completed for each patient and was completed by theatre staff.

Audits of compliance with completion of the WHO checklist showed scores of 100% for November 2017 and earlier scores were consistent with this. This was an improvement since the last inspection. During observation of procedures, we noted the WHO checklist was appropriately completed. This included marking of patients and a trust innovation being use of a green wristband which was signed by the clinicians to confirm the correct patient and procedure. Nurse staffing The trust has reported the following staffing numbers for surgery as at September 2017:

Ward/Site Planned staff (WTE) Number in post (WTE) Bradford Royal Infirmary 284 216 Macular Unit 7 2 Total 291 218

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(Source: Routine Provider Information Request (RPIR) – P16 Total numbers – Planned vs actual tab)

Vacancy rates

From October 2016 to September 2017, the trust reported an overall nursing staffing vacancy rate of 20% in surgery. The trust has set no target vacancy rate.

Bradford Royal Infirmary

Bradford Royal Infirmary reported a vacancy rate among nursing and midwifery staff in surgery of 18% from October 2016 to September 2017.

(Source: Routine Provider Information Request (RPIR) P17 Vacancies)

Turnover rates

From October 2016 to September 2017, the trust reported an overall nursing staffing overall turnover rate of 13% in surgery. The trust has set no target turnover rate.

Bradford Royal Infirmary

Bradford Royal Infirmary reported a turnover rate among nursing and midwifery staff in surgery of 13% from October 2016 to September 2017.

(Source: Routine Provider Information Request (RPIR) P18 Turnover)

Sickness rates

From October 2016 to September 2017, the trust reported an overall nursing staff sickness rate of 5% in surgery. This is slightly higher than the trust’s target sickness rate of 4%.

Bradford Royal Infirmary

Bradford Royal Infirmary reported a sickness rate among nursing and midwifery staff in surgery of 5% from October 2016 to September 2017, which was higher than the trust target.

(Source: Routine Provider Information Request (RPIR) P19 Sickness)

Bank and agency staff usage

Please note that we have been unable to calculate bank and agency usage as a proportion of the total number of shifts available including those covered by permanent staff due to the fact that the total number of bank and agency shifts reported by the trust was often higher than the total number of available shifts.

From October 2016 to September 2017, the trust reported bank usage for registered nurses in surgery of 6,989 shifts and agency usage of 5,569 shifts. There were 2,778 shifts that were unfilled by bank and agency staff. All of these shifts were at Bradford Royal Infirmary.

(Source: Routine Provider Information Request (RPIR) P20 Nursing – Bank and Agency)

We found that nurse staffing figures were displayed in each ward and, with the exceptions explained below, planned staffing numbers matched actual numbers in each ward we visited.

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Nurse staffing was reviewed annually (last review December 2017) and pending the embedding of an electronic safer staffing tool called 'safecare', daily reviews of staffing across wards took place four times a day.

Staffing was on the division’s risk register because the division recognised that, while it achieved safe staffing levels, the position was only maintained with daily close monitoring and use of regular agency staff. We attended one of the bed meetings and saw that daily staffing levels were escalated and discussed by the head of nursing and the matrons for the division. Staff were moved between wards to reach an acceptable staffing level taking into account guidance from the Royal College of Nursing. The system appeared to work effectively because all wards reported that they had the staff required to provide safe care. Theatre staffing levels were planned according to the lists on a daily basis.

We found that on occasions wards ran shifts with registered nurse less than establishment (ward 8, ward 14, ward 26 and ward 27). Where possible these shifts were filled through healthcare assistants. We discussed this with ward sisters; all assured us that at no time were wards unsafe. No variance was found in the night shift across any ward.

The trust was trying to recruit to reduce the reliance on regular agency staff and some staff were attending a recruitment day during our inspection. Other initiatives included recruitment to new roles such as trainee nursing associates. The associates would be able to do all things a registered nurse could do except, for example, medicine administration or bloods. However, once in place and trained it was expected this would free up registered nurses to spend more time on the wards.

The division did use agency nurses but senior ward staff explained to us that they tended to use staff that had experience of working on the ward and mainly used them at night. All agency staff underwent a pre-employment check which included confirmation that they had completed all relevant training.

Senior ward staff orientated agency staff before they worked on the ward. The trust had also created training to support agency staff. For instance, the trust told us the tissue viability team produced some guides for agency staff, to make them aware of expectations around pressure ulcer prevention.

We saw notes of handovers held by staff which appeared detailed and followed a situation, background, action, result format with additional helpful information about patient preferences and risks. Medical staffing The trust has reported the following staffing numbers for surgery as of September 2017. All the staff were at Bradford Royal Infirmary,

Ward/Site Planned staff (WTE) Number in post (WTE) Bradford Royal Infirmary 139 133

(Source: Routine Provider Information Request (RPIR) – P16 Total numbers – Planned vs actual tab)

The following medical staffing information is routinely requested within the universal provider information request spreadsheets, to be completed within a standard template.

Vacancy rates

From October 2016 to September 2017, the trust reported an overall medical staffing vacancy rate of 12% in surgery. The trust has set no target vacancy rate. 20171116 900885 Post-inspection Evidence appendix template v3 Page 132

All the staff were based at Bradford Royal Infirmary.

(Source: Routine Provider Information Request (RPIR) P17 Vacancies)

Turnover rates

From October 2016 to September 2017, the trust reported an overall medical staff turnover rate of 8% in surgery. The trust has set no target turnover rate.

Bradford Royal Infirmary

Bradford Royal Infirmary reported a turnover rate among medical and dental staff in surgery of 8% from October 2016 to September 2017.

(Source: Routine Provider Information Request (RPIR) P18 Turnover)

Sickness rates

From October 2016 to September 2017, the trust reported an overall medical staff sickness rate of 1% in surgery. This is notably better than both the nursing staff performance and the trust target sickness rate of 4%.

Bradford Royal Infirmary

Bradford Royal Infirmary reported a sickness rate among medical and dental staff in surgery of 1% from October 2016 to September 2017, which was lower than the target rate of 4%.

(Source: Routine Provider Information Request (RPIR) P19 Sickness)

Bank and locum staff usage

Please note that we have been unable to calculate bank and locum usage as a proportion of the total number of shifts available including those covered by permanent staff due to the fact that the total number of bank and locum shifts reported by the trust was often higher than the total number of available shifts.

From October 2016 to September 2017, the trust reported bank usage for medical staff in surgery of 482 shifts and locum usage of 752 shifts. There were 349 shifts that were unfilled by bank and locum staff. All of these shifts were at Bradford Royal Infirmary.

(Source: Routine Provider Information Request (RPIR) P21 Medical Locums)

Staffing skill mix

In August 2017, 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 also higher than the England average.

Staffing skill mix for whole time equivalent staff working at Bradford Teaching Hospitals NHS Foundation Trust This England Trust average Consultant 52% 48% Middle career^ 5% 11% Registrar Group~ 27% 30%

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Junior* 16% 11%

^ 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 cover was available on-site 24 hours a day and the division of surgery made use of a number of on call rotas. Consultants were supported at ward level by foundation year one doctors assigned to each ward. We spoke with consultants in the theatres and noted there were no concerns raised about medical cover.

Unlike the previous inspection, junior doctor presence was not an issue. We were told junior doctors were assigned to each ward. Trust-wide the data shows this trust was above the England average for junior doctors.

Post-operative ward rounds were completed daily although this could take place out of hours. We were told medical outliers on a surgery ward awaiting a bed on a medicine ward were seen by consultants from medicine usually before midday each day.

Where locums were used the locum booking team checked the suitability of the locum to work in the trust according to set criteria which included obtaining two references. According to data submitted by the trust the anaesthetics team made most use of locums.

Junior doctors out of hours could call for consultant support. Predominantly this would be by phone with the option to attend site for emergency theatre, emergency procedures or diagnostic procedures.

At weekends the rota was shared and cross-covered with three consultants from another trust. The team of consultants did telephone advice, ward rounds and emergency procedures out of hours.

Anaesthetic consultants also did an out of hours rota to ensure consultant led anaesthesia in emergency theatres was available 24/7 all year.

Records The trust was in the process of migrating all patient records from paper to electronic records and so where paper records were still being used such records were later scanned into the electronic patient record. We reviewed 29 patient records and all were detailed, legible and signed.

In September 2017 the trust began a programme of phased introduction of electronic patient records. We spoke with staff who described the training and support they had received in positive terms. For instance, the trust had ensured that technicians from the company responsible for the new system were on site to support staff. Most of the patient record was electronic and staff used computers on wheels to record patient information. Confidentiality of patient records was enhanced by the computers which required a staff card to access them. Some of the records were paper, e.g. theatres had not yet moved to electronic patient records. The paper element of the records were scanned onto the patient electronic record.

We spoke to staff responsible for ensuring that paper records were available for theatre lists and it was clear that the trust had processes in place to ensure paper records were available to avoid a list having to be cancelled.

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Staff explained that GPs received an electronic discharge letter following a patient receiving treatment at the trust. Medicines We saw the trust had an up to date medicine policy and that medicines ((including controlled drugs (being medicines that require extra checks and special storage arrangements because of their potential for misuse)) were stored and managed safely.

All medicines and intravenous fluids were stored behind keypad locked doors and the nurse in charge carried the keys to gain access to the locked controlled drugs cabinet and locked drugs fridge. On each ward we visited we randomly checked the controlled drugs medicines and medicines stored in the locked fridge and saw that the medicines concerned were in date and that the controlled drugs register showed the correct balance for that drug. This register was checked weekly by two staff and we only found one gap in such checks on one ward out of nine visited.

Minimum and maximum fridge temperatures were checked daily and staff were trained to call the pharmacy team if the fridge went out of maximum range. If this occurred we were told all drugs in the fridge were destroyed.

At the last inspection oxygen was found stacked in the corridor area of the nucleus theatres. We did not find this at this inspection.

On the wards, there was a specific room for storage of medical gases, such as oxygen, this room was used by ward staff. Where a specific room was not available at ward level, we noted, where there was oxygen cylinders present on the ward, there were multiple oxygen cylinders stored standing on the floor with no support and no signage on the door. This is contrary to guidance set out in Medical gases Health Technical Memorandum 02-01: Medical gas pipeline systems – Part B at paragraph 8.23 onwards. We pointed this out to ward staff and on the next day when we went back to check we noted that the oxygen had been removed. Subsequently the trust told us they had written to staff to remind them about the storage of oxygen.

The electronic patient record allowed staff to record allergies and the trust also used a wristband to alert staff that a particular patient had an allergy.

A review of patient records showed that patients had been assessed for risk of blood clots and appropriate treatment was given. Reasons why medicines had been delayed or not given were recorded and medicines were reconciled in a timely way. We observed a staff member reconciling medicines with a patient.

Pharmacist colleagues also reviewed 10 patient clinical records and spoke with one patient. They found medicines, including intravenous fluids, were stored securely and access was restricted to authorised staff. However, stocks of medicines were not always managed correctly as on ward 28 three medicines which had expired were still being stored in the medication stock cupboard. These were removed by the ward manager during our visit.

Controlled drugs were appropriately stored and managed, and balance checks were carried out in accordance with trust policy. The storage and monitoring of medicines requiring refrigeration and found they were managed in accordance with trust policy and national guidance.

Medicines and equipment for emergency use were readily available. Staff carried out regular checks to ensure these were fit for use in line with the trust policy. However, on wards 27 and 28, we found two oxygen cylinders which had expired in December 2017.

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Staff recorded the reason when medicines had been delayed or omitted. The trust audited delayed and omitted doses, but the latest audit we were provided with from December 2017 did not include details of actions put in place to reduce these omissions.

The trust had taken steps to ensure appropriate antimicrobial use to optimise patient outcomes and to reduce the risk of adverse events and antimicrobial resistance. For example, electronic prescriptions contained indications and stop dates. In addition, where patients had been prescribed intravenous antibiotics, we saw these were regularly reviewed and changed to oral alternatives in a timely manner.

We found that all patients we reviewed had been appropriately assessed for the risk of Venous Thromboembolism (blood clots) and appropriate prophylaxis had been prescribed where this was indicated.

A medicine safety group oversaw audits on antibiotic choice and prescription chart documentation and received reports about medicine related issues such as missed doses, fridge monitoring reports, and serious incident reports relating to medication. An audit of prescription chart documentation to ensure stop and review dates were shown (to reduce unnecessarily prolonged courses) and indication for use (to allow pharmacists to check against protocol) showed compliance of 70%. The medicine safety group identified the use of electronic prescribing in electronic patient records (which introduced mandatory fields) would support better compliance going forward. This received some support from our review of records which showed that intravenous antibiotics were regularly reviewed and changed to oral ones in a timely way.

Staff described how the pharmacy team carried out spot checks at ward level on the storage, management and administration of medicine. A clinical pharmacy service was available to inpatients; this was focused primarily on patient flow and medicines reconciliation. Dispensary services were provided for inpatients and discharge prescriptions. The ward clinical pharmacy service was available on the admissions units ten hours a day, 7 days each week. An on-call pharmacist was available 24/7. Incidents Never Events

Never events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. 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 2016 to October 2017, the trust reported one incident classified as a never event for surgery. This incident, which occurred in April 2017, involved the wrong lens being implanted during cataract surgery. The patient required a subsequent procedure to implant the correct lens.

(Source: Strategic Executive Information System (STEIS))

We reviewed the root cause analysis of the above never event which involved insertion of the wrong power of lens. The report we saw revealed that there had been a full and robust investigation into the never event with a view to identifying lessons learnt. One of the senior leadership team checked that learning had been embedded. When in the ophthalmology theatres we saw how learning from the never event was in place. For instance, we saw staff using the whiteboards to help them confirm that the correct lens was being used. The ‘WHO Ophthalmology check list’ had been updated to reflect the trust’s established format.

This was an improvement from the last inspection where we noted issues with theatre staff

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Breakdown of serious incidents reported to STEIS

In accordance with the Serious Incident Framework 2015, the trust reported 19 serious incidents (SIs) in surgery which met the reporting criteria set by NHS England from November 2016 to October 2017. Of these, the most common types of incident reported were:

 Pressure ulcer meeting SI criteria with 16 (84% of total incidents).  Treatment delay meeting SI criteria with 1 (5% of total incidents).  Abuse/alleged abuse of adult patient by staff with 1 (5% of total incidents).  Surgical/invasive procedure incident meeting SI criteria with 1 (5% of total incidents).

(Source: Strategic Executive Information System (STEIS))

Staff we spoke with on the wards and in the theatres we visited knew how to report incidents and could describe lessons that had been learnt. For instance, we were told how changes were made to storage of medicines containing penicillin and we saw posters on the ward reminding staff of best practice for medicine administration, including use of two nurses to confirm the correct medicine, patient, route and dose.

As can be seen above, the largest category of serious incidents concerned pressure ulcers. In order to tackle this issue the trust told us about an initiative to support staff in managing pressure ulcers. The trust said a prevention of pressure ulcers meeting took place monthly and reviewed the outcome of all root cause analyses for hospital acquired category 3 and 4 pressure ulcers or those that had deteriorated to category 3 or 4 since admission. Action plans were devised for the relevant areas, and themes were also collated and shared with all areas, to ensure wider learning. Themes were addressed as part of the work plan for the group.

Staff we spoke with were aware of the trust’s system to manage pressure ulcers. It involved staff regularly assessing patients which included use of a scoring system called 'Waterlow'. Any patient with a score at 10 or above was given an individualised care plan which detailed how any pressure ulcers would be handled. Staff explained to us that this may have included ordering an air mattress or turning the patient at regular intervals. Pressure ulcer care was monitored at handover and through the electronic patient record system. We saw from an electronic patient record how staff were able to track pressure ulcer care of a patient.

The duty of candour is a regulatory duty that relates to openness and transparency and 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. Staff we spoke with demonstrated an awareness of the duty and the importance of being open and honest when delivering care. According to data supplied by the trust, over the last 12 months, the surgery division applied duty of candour 49 times.

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Staff described various ways in which learning was shared about incidents such as safety huddles, at handovers, and during monthly ward meetings. In addition, on the wards there were communication folders or monthly bulletins displayed, for staff to see and read. One of the monthly bulletins concerned the trust’s new review process for mortality.

We noted when speaking with staff that there was no facility to enable staff to indicate that they wanted feedback about any incident they reported. We raised this with the trust and were told that it was developing a solution to enable staff to indicate electronically when completing the incident report that they wished to receive feedback.

Matrons were responsible for sharing lessons learnt at ward level with the senior and junior sister within each ward and their staff. Matrons also met regularly with their ward leadership and the head of nursing for the surgery division to discuss learning from incidents.

Mortality and morbidity was discussed at regular mortality sub-committee meetings, minutes for which we have reviewed. The trust told us one of its priorities is mortality and that it had set up a mortality review improvement programme. This programme aimed to increase the percentage of inpatient deaths that the trust reviewed, promote the review methodology across the trust (which we saw evidence of when visiting the wards) and strengthen mortality monitoring and governance processes.

Major incident awareness and training The trust had major incident and business continuity plans in place that could be accessed via the trust’s intranet. The trust’s major incident plan provided guidance for departments and staff.

Senior managers considered seasonal demands when planning surgical capacity within the trust.

The trust followed NHS England guidance on the Operational Pressures Escalation Levels Framework. This framework supported managers with demand pressures and escalation procedures.

We saw that the trust had undertaken a ‘black ice’ training exercise in the winter of 2017 to determine the trust’s preparedness for a major incident. A report had been produced which identified learning, recommendations and areas of good practice.

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 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 45 new pressure ulcers, 24 falls with harm and seven new catheter urinary tract infections from October 2016 to October 2017 for surgery.

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

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Total Pressure ulcers (45)

Total Falls (24)

Total CUTIs (7)

(Source: NHS Digital)

Unlike the previous inspection, while the wards still used the safety thermometer, the results were not on display to the public. The trust told us that safety thermometer results were instead usually displayed in the room used at ward level by staff. We randomly selected some staff rooms on some wards but did not see safety thermometer results displayed.

Is the service effective? Evidence-based care and treatment We saw trust policies and pathways were based on guidance from the Royal College of Surgeons and the National Institute for Health and Care Excellence (NICE). New guidance was monitored through clinical governance meetings and we saw evidence of this through a review of clinical governance reports. The surgical division had care plans and pathways for a number of conditions including stroke, deep vein thrombosis (DVT), cellulitis, rapid access chest pain and sepsis based on the acute toolkit, screening tool and care protocols. Staff accessed policies, procedures and other guidance through the trust intranet. We reviewed policies and found them to be in date with version control and a named author. Integrated pathways were in use for patients undergoing day surgery procedures including documentation to assess risk such as venous thromboembolism (VTE). Enhanced recovery pathways were in place, for example for patients undergoing elective joint replacement surgery. Audits were undertaken for the completion and accuracy of care bundles, the use of NEWS, medication and documentation such as those which related to infection prevention and control. Results showed good levels of compliance. Ward sisters completed trust-wide nursing audit programmes and we saw results and action plans in ward files.

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The surgical division participated in a number of national audits including the national hip fracture database and the national bowel cancer audit programme. Staff records reflected training initiated and completed. Medical staff undertook clinical audits and these were discussed at clinical governance meetings. Nursing staff completed a number of audits on patient experience and outcomes, these audits were completed internally and were completed by observation or review of documents. These audits included medicines administration, environment and hand hygiene. Nutrition and hydration We reviewed care plan documentation and risk assessments of 29 patients on wards at BRI. These were fully completed and fluid, food and intentional rounding charts were completed appropriately.

Staff had identified patients at risk of malnutrition, weight loss or requiring extra assistance at mealtimes. Staff used the Malnutrition Universal Screening Tool (MUST) tool to identify adults who were malnourished or at risk of malnutrition. We observed protected meal times were in place and saw patients supported to eat and drink. Patients gave positive feedback about the variety and quality of food choices available. Drinks were readily available and in easy reach of patients.

Patients were assessed regarding their nutritional needs and these were recorded in care plans; patients were referred to the dietician for additional advice if required. Systems were in place to identify patients who needed additional support with eating and drinking.

Policies were in place regarding fasting times and intravenous fluids in line with best practice. We saw records in notes for patients who received nutrition via nasogastric tubes, including the day and reason for insertion, the type of tube, measurement, aspirate pH and a confirmation that consent had been obtained. Pain relief We reviewed care plans related to pain management. Pain assessments were carried out and recorded in patient notes. Pain relief was provided as prescribed and there were systems in place to make sure that additional pain relief was accessed through medical staff, if required.

Patients we spoke with had no concerns about how their pain was controlled and staff checked that pain relief administered had been effective. We were assured about the assessment of pain for those patients who may not be able to communicate were in pain.

Staff used a pain-scoring tool to assess patient’s pain levels; staff recorded the assessment on paper and electronic records. We saw evidence of pain scores in patient documentation reviewed.

Patient outcomes Relative risk of readmission

Trust level

From July 2016 to June 2017, patients at the trust had higher than expected risks of readmission for both elective and non-elective admissions when compared to the England averages.

The risk of readmission for ENT is slightly better than the England average, with the Urology and General Surgery specialties performing below the England average. Of note, the performance of General Surgery is notably worse than the England average by several orders of magnitude.

Non–elective admissions show a more stable trend. The General Surgery specialty is performing

20171116 900885 Post-inspection Evidence appendix template v3 Page 140 slightly below the England average, with Urology and Trauma and Orthopaedics performing similar to the England averages.

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 is represents the opposite. Top three specialties for specific trust based on count of activity

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 is represents the opposite. Top three specialties for specific trust based on count of activity

(Source: HES - Readmissions (01/07/2016 - 30/06/2017))

We discussed the higher than expected risks of readmission for both elective and non-elective admissions when compared to the England averages with the divisional management team. When we interviewed the division’s senior management team, they were aware of the high re- admission rates but were certain that this was not caused by clinicians sending patients home when they were not clinically fit. While accepting that the situation impacted on patient experience and bed management, the team told us the issue was being addressed by a review to identify the causes of the elevated expected risks of readmissions, the effects upon patients readmitted and methodologies for bringing the risks of readmission in line with England averages.

Hip Fracture Audit

In the 2016 Hip Fracture Audit, the risk-adjusted 30-day mortality rate for Bradford Royal Infirmary was 8.3% which was within the expected range. The 2015 figure was 7.5%.

The proportion of patients having surgery on the day of or day after admission was 88.4%, which was better than the national standard of 85% and notably better than the national aggregate of 70.6%. The 2016 figure was 84.4%.

The perioperative medical assessment rate was 98.1%, which failed to meet the national standard of 100%. The 2016 figure was 96.6%.

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The proportion of patients not developing pressure ulcers was 99.7%, which falls in the top 25% of trusts. The 2016 figure was also 99.7%.

The length of stay was 24.4 days, which falls in the middle 50% of trusts. The 2016 figure was 12 days.

(Source: National Hip Fracture Database 2017)

Bowel Cancer Audit

In the 2016 Bowel Cancer Audit, 72.4% of patients undergoing a major resection had a post- operative length of stay greater than five days. This was worse than the national aggregate. The 2015 figure was 72.6%.

The risk-adjusted 90-day post-operative mortality rate was 1.6% which was within the expected range. The 2015 figure was 0%.

The risk-adjusted 2-year post-operative mortality rate was 23.3% which was within the expected range. The 2015 figure was 30.4%.

The risk-adjusted 30-day unplanned readmission rate was 10.2% which was within the expected range. The 2015 figure was not reported.

The risk-adjusted 18-month temporary stoma rate in rectal cancer patients undergoing major resection was 44.1% which was within the expected range. The 2015 figure was 47.3%.

(Source: National Bowel Cancer Audit)

National Vascular Registry

In the 2017 National Vascular Registry (NVR) audit, the trust achieved a risk-adjusted post- operative in-hospital mortality rate of 1.7% for Abdominal Aortic Aneurysms, indicating that the trust is performing within the expected range. The 2016 figure was 1.9%.

Within Carotid Endarterectomy, the median time from symptom to surgery was 14 days, equal to the national standard.

The 30-day risk-adjusted mortality and stroke rate was within the expected range at 1.6%. The 2016 figure was 0%.

(Source: National Vascular Registry 2017)

Oesophago-Gastric Cancer National Audit

In the 2016 Oesophago-Gastric Cancer National Audit (OGCNCA), the age and sex adjusted proportion of patients diagnosed after an emergency admission was 2.7%.

The 90-day post-operative mortality rate was 4.6% which was within the expected range. The 2015 rate was 7.8%.

The proportion of patients treated with curative intent in the Strategic Clinical Network was 34.3%, significantly lower than the national aggregate.

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This metric is defined at strategic clinical network level; the network can represent several cancer units and specialist centres); the result can therefore be used a marker for the effectiveness of care at network level; better co-operation between hospitals within a network would be expected to produce better results.

(Source: National Oesophago-Gastric Cancer Audit 2016)

National Emergency Laparotomy Audit

In the 2016 National Emergency Laparotomy Audit (NELA), Bradford Royal Infirmary achieved an amber rating for the crude proportion of cases with pre-operative documentation of risk of death. This was based on 157 cases.

The trust achieved a green rating for the crude proportion of cases with access to theatres within clinically appropriate time frames. This was based on 118 cases.

The trust achieved a green rating for the crude proportion of high-risk cases with a consultant surgeon and anaesthetist present in the theatre. This was based on 98 cases.

The trust achieved a green rating for the crude proportion of highest-risk cases admitted to critical care post-operatively. This was based on 71 cases.

The risk-adjusted 30-day mortality for the trust was within the expected range at 12.8%, based on 157 cases.

(Source: National Emergency Laparotomy Audit)

The trust had received a concern (September 2017) from the National Joint Registry (NJR) Outlier Committee drawing attention to the mortality rate for knee replacements. The NJR’s review of the standardised mortality rate over the last five years had shown the trust lies between the 95% and 99.8% control limits, which Healthcare Quality Improvement Partnership and the National Joint Registry regarded as an ‘Alert (borderline outlier) status’.

The senior management team were aware of the alert and had assigned a senior member of clinical staff to examine and validate trust data and to carry out an audit of the mortality cases. This had been confirmed to the NJR

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 2015/16 performance on groin hernias was slightly better than the England average, with a particularly strong performance in Groin Hernia – EQ VAS.

For hip replacements, performance was about the same as the England average.

For Knee replacements, performance was about the same as the England average.

For Varicose Veins, performance was slightly worse than the England average.

(Source: NHS Digital)

Competent staff Appraisal rates

From October 2016 to September 2017, 90% of staff within surgery at the trust had received an appraisal compared to a trust target of 100%. Appraisal data was not provided for the medical and dental staff subgroup within surgery. The trust also reported more administration and clerical staff completing an appraisal than were eligible - this is likely to be a recording error.

A split by staff group can be seen below:

Appraisals Appraisals Appraisal Trust Target Staff group completed required rate Target met? Admin & Clerical 82 79 104% 100% Yes Nursing & Midwifery registered 213 233 91% 100% No Additional Clinical Services 85 100 85% 100% No Add Prof Scientific & Technical 29 40 73% 100% No Estates & Facilities 3 5 60% 100% No

Bradford Royal Infirmary

From October 2016 to September 2017, 90% of staff within surgery at Bradford Royal Infirmary had received an appraisal compared to a trust target of 100%. A split by staff group can be seen below:

Appraisals Appraisals Appraisal Trust Target Staff group completed required rate Target met? Admin & Clerical 82 79 103.8% 100% Yes Nursing & Midwifery registered 213 233 91.4% 100% No 20171116 900885 Post-inspection Evidence appendix template v3 Page 144

Additional Clinical Services 82 96 85.4% 100% No Add Prof Scientific & Technical 29 40 72.5% 100% No Estates & Facilities 3 5 60.0% 100% No

(Source: Routine Provider Information Request (RPIR) P43 Appraisals)

Multidisciplinary working Nursing and medical staff reported good multidisciplinary working and all surgical wards participated in multidisciplinary ward rounds. This resulted in a co-ordinated approach to treatment plans and decisions.

Multidisciplinary safety huddles took place each morning to discuss patient care and identify risks as well as to share other information. Physiotherapy and occupational therapy staff supported wards throughout BRI and helped with continuity of care.

Specialist nurses were available to review patients in specialties, such as respiratory and diabetes, physiotherapy, speech and language, pharmacy, child and adolescent and adult mental health liaison. Trauma specialist nurses visited wards daily to review patients and liaised with day surgery following trauma meetings if admissions were required. Specialists were also available to support staff groups with training and to participate in multidisciplinary meetings to discuss patient care and treatment. Allied Health Professionals confirmed there was good multidisciplinary working and also offered training to nursing staff where appropriate. Dieticians completed daily reviews of those patients referred for their input.

There was a multidisciplinary approach to assessment and facilitated discharge working closely with dedicated discharge co-ordinators.

Seven-day services The trust monitored its working scheme against NHS Services, Seven Days a Week Clinical Standards.

Consultants provided seven-day cover for surgical wards and the assessment unit. On-call consultants covered weekends and nights. Daily consultant ward rounds took place and we saw evidence of reviews at weekends and patients confirmed this.

There was availability of physiotherapy and occupational therapy staff Monday to Friday and physiotherapists covered weekends on a rota system to deliver interventions to identified patients on a priority of need basis. Health promotion Support was available for patients with smoking cessation which was discussed with patients as appropriate. There were also procedures in place to support patients withdrawing from drugs or alcohol and the pharmacist gave advice and support when necessary.

Individual assessments of care needs were undertaken on admission and the multidisciplinary team provided health and care advice to patients to enable them to manage their own conditions.

In wards and patient areas we saw health promotion advice and information displayed. For example, on the importance of keeping hydrated and having a healthy diet.

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Access to Information Electronic patient records (EPR) provided up to date information such as patients with a dementia or who were diabetic. Estimated discharge dates were also displayed within the record. Staff reported prompt responses to information and test results such as blood results, x-rays and scan results which could be accessed through the EPR.

Discharge summaries were sent to the patient’s general practitioner (GP) to inform the GP of the patient’s treatment in hospital.

Training, guidance, policies and procedures were accessed through the staff intranet. Consent, Mental Capacity Act and Deprivation of Liberty Safeguards Mental Capacity Act and Deprivation of Liberty training completion

The trust set a target of 95% for completion of safeguarding training. The trust reported that 12% of eligible staff within surgery had completed Mental Capacity Act (MCA) training within the current year at the time of inspection. Plans were in place to improve the staff completion rate. Staff spoken with demonstrated an understanding of consent, mental capacity and ‘best interest’ decisions and accessed training through e-learning. Staff had accessible guidance and information and knew who to contact for advice and support, if needed. During discussion staff had an understanding of how to assess capacity and when this should be done and by whom. We reviewed patient records and saw that Mental Capacity Act (MCA) assessments had been undertaken by the doctor responsible for the patient’s care. Nursing records with DoLS in place showed the appropriate paperwork had been completed.

We observed staff providing explanations and obtaining consent prior to completing procedures. Staff told us best interest meetings were held for patients who lacked capacity to make decisions for themselves.

Is the service caring?

Compassionate care Friends and Family test performance

The Friends and Family Test response rate for surgery at Bradford Teaching Hospitals NHS Foundation Trust of 19% was worse than the England average of 25% from October 2016 to September 2017.

Staff did engage with patients to obtain their feedback and increase the FFT response rate. On the wards we were shown iPads on which patients could complete a quick and easy survey and were also shown feedback cards that patients were given. We saw boxes on the wards in which patients could leave their feedback and there were promotional posters on some wards about giving feedback.

When asked about the low response rate staff explained that it was challenging to obtain feedback from patients because once their care had finished they were just focussed on getting home.

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We were not made aware of any initiative at ward level to increase the level of feedback received from patients. The trust told us it tried to engage with patients by: monitoring NHS Choices & Patient Opinion posts, publishing the patient experience email address on its website so patients or others could write directly to the patient experience team, and by providing social media accounts on which patients could leave feedback.

A breakdown of FFT performance by ward for surgical wards at the trust with total responses over 100 is below. All wards had annual recommendation rates above 90%.

Highest score to Lowest score Key 100% 50% 0%

Note - 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.

Note: sorted by total response

(Source: NHS England Friends and Family Test)

As can be seen above, the surgery division was recommended by patients scoring over 90% based on annual performance. This accorded with our discussions with patients. The trust told us the division’s central management team and complaints experience manager have done a lot of work to enable them to collate patient feedback for each ward in the division.

Patients we spoke with described the care they had received in positive terms. Words and phrases included: “excellent”, “can’t knock it”, “very good”. Only two of the patients we spoke with mentioned negative feedback. Yet even they confirmed that the trust was attentive to their feedback and said that they were being kept informed of what the trust was doing to address their concerns.

When walking around the wards we saw how staff dealt compassionately with patients and responded promptly to call bells or requests for assistance. Staff appeared to have enough time for patients and patients told us they introduced themselves. All patients seen looked clean and well cared for and many of them were dressed, out of bed, and able to move around, with staff assistance where necessary.

We saw staff use doors and curtains to enhance patient privacy and dignity. On the wards that were open plan with just curtains, in addition to using curtains, staff supplied earplugs to patients to help them cope with the noise on the ward and to support them in trying to sleep better. Emotional support The trust had a multi-faith chaplaincy service and a bereavement service which staff could access to support patients or carers who needed support. The trust had completed a bereaved carers survey in 2017. Results showed that 71% of carers felt staff listened to patients worries, 90% felt staff treated patients with dignity in their last days of life, 76% felt staff treated carers in a sensitive way, and 81% felt that care was excellent or good.

On one ward, staff told us that when booking in patients requiring a termination of pregnancy they

20171116 900885 Post-inspection Evidence appendix template v3 Page 147 ensured that they were booked into one of the bed bays that lay off of the main open plan ward. This provided a more intimate and appropriate environment for the patients.

A patient we spoke with described how they were upset and how a staff member noticed them and came and spoke with them and how nice and supported this interaction made them feel.

On one ward we visited they had used ‘A' level student volunteers to visit patients on the ward and talk to them. Staff told us they were encouraged to talk to patients whatever they were doing, whether when cleaning or giving a cup of tea, and we saw staff taking talk to patients when attending to them. Understanding and involvement of patients and those close to them We saw from reviewing handover notes and from interactions staff had with patients that staff had tried to understand patient needs or those close to them. For instance, on one ward we noted how staff attended to a patient who was shouting out, and phoned their relative, so that they could give the necessary re-assurance the patient needed.

When we spoke to patients they told us that they knew what they were waiting for and had been told what was being done in a way they could understand so that they felt involved in their care.

The trust told us that they had created easy read guides for patients with learning disabilities in relation to pain. Further, the trust had successfully bid for funding for distraction and engagement resources to help with patients with learning disabilities. The trust had also set up a learning disabilities forum, which was attended by matrons, heads of nursing and other stakeholders. The trust told us the forum met quarterly to share good practice and understand patient experiences related to patients with a learning disability.

Is the service responsive?

Service delivery to meet the needs of local people Policies and pathways were based on NICE and Royal College of Surgeons guidelines and were available to staff and accessible on the trust intranet site.

The surgical division had care plans and pathways for a number of conditions, e.g. sepsis. Staff accessed policies, procedures and other guidance through the trust intranet. We reviewed policies and found them to be in date with version control and a named author.

All surgical wards and patient areas were spacious and side rooms were available for those who needed them. There were designated areas for those waiting for surgery and post-operative patients. The service was nurse led with clear discharge guidelines.

There were specialist dementia nurses employed by the trust and access to learning disability liaison support. Staff we spoke with felt confident in caring for patients who may need additional support.

Average length of stay

Trust Level The trust’s performance for elective and non-elective admissions relating to overall length of stay is better than the England average. The performance in the non-elective specialty of Trauma and Orthopaedics is particularly noteworthy, being 3.9 days shorter than the England average.

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Elective Average Length of Stay – Trust Level

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

Non-Elective Average Length of Stay – Trust Level

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

(Source: Hospital Episode Statistics)

Meeting people’s individual needs All wards were dementia friendly and had a wide range of literature and resources available for people living with and caring for people with a dementia. The trust had a lead nurse for dementia and patients were screened on admission for dementia, depression or delirium.

Matrons at ward level and the safeguarding team were responsible for identifying patients with learning disabilities or those that were severely deaf or blind and staff used the ‘close the gap tool’ to assess their needs. Patients with diabetes were put on a specific insulin care plan and there was mandatory training on insulin administration.

Wards and patient areas were accessible for people who used a wheelchair or walking aids. Disabled toilets and showering facilities were available in the all areas inspected.

Assessments took place on admission and during pre-assessment. This identified individual patient’s needs and this information was used to inform care planning. We were assured that staff were aware and responsive to the needs of different people.

Different food choices and chaplaincy for different religions and faiths were available. Staff were proactive in planning for the needs of bariatric patients. This was identified at pre-assessment and all necessary equipment was obtained in advance of surgical procedure.

Side rooms were used for patients who were particularly anxious, living with severe autism or a learning disability or those patients who needed isolation. Staff told us a MDT meeting was held to plan these admissions. This minimised distress to the patient as far as possible.

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Staff on all wards gave examples of reasonable adjustments made to improve the patient experience, such as flexible visiting hours and family members being involved in meeting patients’ care and emotional needs. This was confirmed through feedback from patients and relatives during the inspection.

Translation services were available and staff knew how to access these. Information leaflets were available for patients; these were available in languages other than English. Access and flow Referral to treatment (percentage within 18 weeks) - admitted performance

From October 2016 to August 2017 the trust’s referral to treatment time (RTT) for admitted pathways for surgery performed slightly below the England average for much of the reporting period. October 2016 the June 2017, the trust was slightly below the England average. From June 2017 onwards the trust’s performance increased to bring it to a similar level to the England average. No data was submitted for September 2017.

(Source: NHS England)

Each morning (0800) staff took part in a ‘huddle’, followed by a ‘bed meeting’. At 1230 a bronze meeting to check actions from the earlier meetings was completed, followed by a further bed meeting and then a final catch up meeting at 1630.

We attended a bronze meeting led by the head of nursing and matrons for each directorate together with a business manager. This meeting discussed staffing and flow of patients, discharges, any other risks, and set the time for the final meeting of the day.

Referral to treatment (percentage within 18 weeks) – by specialty

A breakdown of referral to treatment rates for surgery broken down by specialty is below. Of these, Urology was above the England average and the other four specialties were below the England average.

Specialty grouping Result England average General Surgery 55% 73% Neurosurgery 0% 70%

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Plastic Surgery 71% 83% Trauma & Orthopaedics 47% 62% Urology 88% 77%

(Source: NHS England)

Following the inspection, the division provided information for November 2017, which showed the following RTTs:

Specialty grouping Result England average General Surgery 62% 73% Neurosurgery 0% 70% Plastic Surgery 71% 83% Trauma & Orthopaedics 73% 62% Urology 80% 77%

The division had contracted all non-complex trauma and orthopaedics to the private sector, signed up to the ‘get it right first time’ initiative and commenced a new process for capacity and demand in ENT as well as the recruitment of additional consultants. The senior management team was confident this had resulted in an improvement to the RTT for trauma and orthopaedics and would continue to do so. Total theatre utilisation during 2017 was 77%. Bed occupancy over the previous financial year for the trust was 83% or below for general and acute beds. Estimated dates of discharge were planned for all patients. The discharge management team supported patients and staff with complex discharges. The discharge team supported surgical wards if they had medical patients. They looked at admission avoidance as well as supporting safe discharges. The day surgery unit proactively managed afternoon theatre lists to ensure they have adequate patients had sufficient recovery time to be able to go home.

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

Over the two years, the percentage of cancelled operations at the trust where the patient was not treated within 28 days was generally stable, with a notable short term decline in Q4 2016/17. Despite this, the trust’s performance was better than the England average.

Percentage of patients whose operation was cancelled and were not treated within 28 days - Bradford Teaching Hospitals NHS Foundation Trust

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Over the two years, the percentage of cancelled operations at the trust showed a trend of decline, and was generally higher than the England average. Cancelled operations as a percentage of elective admissions only includes short notice cancellations.

Cancelled Operations as a percentage of elective admissions - Bradford Teaching Hospitals NHS Foundation Trust

(Source: NHS England)

Trust information showed that the main reasons for cancellation were patient ‘not fit for surgery or anaesthetic’ (29%) and patient ‘did not attend’ (27%).

Learning from complaints and concerns Summary of complaints

From October 2016 to September 2017 there were 222 complaints about surgery. The trust took an average of 55 days to investigate and close complaints; this is not in line with their complaints policy, which states complaints should be resolved within 30 days of receipt. The most common cause of complaint was recorded as ‘aspects of clinical treatment’ with 102 complaints, appointments and cancellations being the next most common with 39 complaints.

Bradford Royal Infirmary

There were 221 complaints which took an average of 55 days to investigate and close. One hundred and two complaints related to ‘aspects of clinical treatment’ and 39 complaints to appointments and cancellations.

(Source: Routine Provider Information Request (RPIR) P61 – Complaints)

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Complaints trends were reported and monitored at the divisional Clinical Governance Committee. Most complaints were caused by cancellations and also clinical outcome.

Staff we spoke with explained how they would deal with a patient’s concerns immediately and, wherever possible as they arose. They escalated concerns to their ward sister or manager, when necessary. Staff were able to signpost patients to the Patient Advice and Liaison Service department where appropriate.

All complaint response letters were sent to senior managers within the care group to ensure they were sighted on all complaints.

Staff were able to give examples of complaints that had happened in their area and were aware of the findings from investigations and any actions that were needed. Records of complaints and action plans were held in staff information files available on wards.

The divisional management team were aware of the issues causing delays to investigating and responding to complaints and had set timescales and had provided more resources to reduce the delays.

Is the service well-led?

Leadership The surgical division had a management structure in place with clear lines of responsibility and accountability. The division was managed by a Divisional General Manager, Divisional Clinical Director and a Head of Nursing; the team was supported by heads of service, business and service managers and matrons. The senior management team had a clear and comprehensive understanding of the current risks, challenges and pressures impacting on service delivery and patient care. Staffing levels were planned so that ward sisters were given management time with other senior nurses in their teams. All ward sisters said they were supported well by the senior management team and that members of the board were visible and regularly visited the wards. At ward level staff said they were well supported by their managers, they were visible and provided clear leadership. The majority of staff told us they felt more supported and confident to escalate any concerns. Ward sisters said they had constructive and positive relationships with matrons and that they visited wards on a daily basis. Staff felt managers communicated well and kept them informed about the management of the wards and service changes. Staff were encouraged to undertake professional development and received annual appraisals. Staff told us they would be confident to raise a concern with their managers and were confident this would be investigated appropriately. Vision and strategy The senior management team was clear about the vision and strategy for the service. There were visual displays of the vision and strategy within the division and the vision and strategy had been communicated throughout the division. The trust’s ‘Clinical Service Strategy 2017 to 2022’ identified a vision to be “an outstanding provider of healthcare, research and education, and a great place to work.” The mission of the trust was to provide the highest quality healthcare at all times and had developed its strategy around four themes - high quality care, research-led care and learning, collaborative hospital care and connected local care. The strategy had been developed into local divisional action plans and local objectives.

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Culture Staff told us the division had strong leadership and senior managers were visible and engaged with staff. We interviewed a number of staff on an individual basis and held group discussions throughout the wards when possible. Staff spoke positively about the service they provided for patients and high quality care was a priority. All staff were clear about their roles and responsibilities, patient-focused, and worked well together.

At ward level, we saw staff show respect between specialities and across disciplines. We saw examples of good team working on the wards between staff of different disciplines and grades.

All staff felt they received appropriate support from management to allow them to perform their roles effectively. Staff reported an open and transparent culture on their individual wards and felt they were able to raise concerns. Staff said there was a strong culture of learning and improvement and training and development was actively encouraged.

We observed senior doctors supporting junior doctors; junior doctors reported feeling very supported and able to ask for advice. Nursing staff reported a positive culture and good working relationships between staff groups. Ward sisters told us that they had appropriate access to senior staff members. This included access to support and leadership courses to help them in leading their services. Governance Divisional management meetings, operational team meetings and clinical governance meetings took place each month. The risk register, incidents, complaints and lessons learned were discussed. Matrons and ward sisters disseminated information with ward staff at ward meetings and safety huddles. The leadership team reported directly to the executive board, and systems were in place to allow information from the team to be shared at ward level. We reviewed the clinical governance meeting minutes (October 2017, November 2017) for the Division of Anaesthesia, Diagnostics and Surgery; these meetings were well attended. The meeting discussed and reviewed serious incidents and never events, pressure ulcers, falls and the ‘Divisional Incident Action Log’. There was also discussion around the risk incident report and themes and trends in incident reporting and additions to the risk register. Complaints, compliments and audit results were also discussed. Mortality and morbidity was discussed at regular mortality sub-committee meetings. The trust had set up a mortality review improvement programme. This programme aimed to increase the percentage of inpatient deaths that the trust reviewed, promote the review methodology across the trust (which we saw evidence of when visiting the wards) and strengthen mortality monitoring and governance processes. We met with senior staff who were motivated and enthusiastic about their roles and had clear direction with plans in relation to improving patient care. Ward sisters, senior managers and clinical leads displayed knowledge, skills and experience. Staff at different levels were clear about their roles and understood their level of accountability and responsibility. Management of risk, issues and performance The directorate had a risk register, which was detailed and thorough in identifying, recording and managing risks, issues and mitigating actions. Governance meeting minutes showed risk registers were reviewed regularly.

Among the highest risks identified were ‘staffing levels on the wards are not adequate to ensure effective and safe patient care...due to planned and unplanned leave, vacancy levels, sickness absence, poor fill rates for bank shifts and recruitment and retention gaps’.

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Other high risks identified were ‘a backlog of continence follow up patients due to single handed consultant’ and ‘ability to provide a sustainable service in particular the delivery of complex cancer cases’. We discussed these with the senior management teams who were well informed about the difficulties and had action plans in place to address the issues.

There was a systematic programme of clinical and internal audit, which was used to monitor quality and systems to identify where action should be taken. All senior staff in the division were responsible for monitoring performance and quality information. Matrons conducted audits of the ward areas with ward sisters to measure quality. Incidents and sharing of information took place on wards and patient areas through daily huddles. Information management Staff accessed information relating to polices and guidance electronically. The system was easy to navigate. Staff received training on information governance and were aware of the importance of managing confidential patient information. Engagement Public engagement Staff were clear about their roles and responsibilities, patient focused and worked well together to engage patients and families. Between July 2016 and June 2017, the Friends and Family Test response rate for surgery at the trust was 19%, worse than the England average of 29%. The FFT showed all wards had annual recommendation rates above 90%. Patients were very complimentary about the care and treatment at the trust. People using the service were encouraged to give their opinion on the quality of service they received. Leaflets about the friends and family test, and the Patient Advice and Liaison Service were available on all ward and reception areas. Internet feedback was gathered along with complaint trends and outcomes. Ward sisters were visible on the ward, which provided patients opportunity to express their views and opinions. Discussions with patients and families regarding decision making was recorded in patient notes. We saw thank you cards and letters displayed at the entrances to wards.

Staff engagement The 2016 NHS staff survey results were presented to the Executive Management Team (EMT) and the Quality and Safety Committee in March 2017. An action plan was developed to increase engagement through developing and improving culture, leadership and communication. Progress against the action plan was monitored by the Education and Workforce Sub-Committee and the Executive Management Team, reporting as necessary to the Quality and Safety Committee. We were told that management engaged with the staff well and we saw senior managers communicate to staff through the trust intranet, e-bulletins, team briefs and safety huddles. Each ward held staff meetings when issues for continuous service development were discussed. All staff were able to voice their opinions and speak with the ward sister, receive feedback and discuss any concerns. Staff we spoke to said they felt appreciated by the ward sister and more senior managers and listened to when they raised concerns.

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During discussions with the senior management team the following innovative practices were identified:  ensuring the right patient gets the right operation by adding a green wrist-band at the time of consent. This is then cross-checked in the anaesthetic room.  the division has recruited physician associates, nurse associates and advanced nurse practitioners.  the division took part in the trust Senior Leadership Team Programme.  a ‘Standard Operating Procedure for full capacity’ protocol has been developed to manage the conversion to non-elective beds on the day case unit.  the development of paperless radiology reports through care records integrated with the theatre and ophthalmology systems.  pilot centre for the RCS England Cholecystectomy Quality Improvement Collaborative, to improve pathways and outcomes by reducing unwarranted variation on service provision.  development of a virtual acute surgical ward to manage patients with specific conditions in surgery (such as abscesses or uncomplicated biliary colic) at home while they await their urgent operation.  provision of a robotic partial nephrectomy to combine the benefits of robotic surgery with the benefits of a nephron-sparing operation, preserving kidney function. Provision of a robotic radical cystectomy surgery allowing the treatment of aggressive bladder cancers with a minimally-invasive approach, shortening lengths of stay and recovery times for patients, with no oncological compromise.  at the forefront of ultrasound diagnosis and in negotiation to be a reference site; started providing intra-corporeal ‘drop in’ ultrasound for intra-operative scanning during laparoscopic operations.  at the forefront of computer tomography scanning and a reference site; generate the highest quality imaging for cross-sectional diagnosis in early disease, such as cardiac vessel atheroma.  collaboration with Airedale NHS Foundation Trust to provide local laboratory services to meet the needs of clinical users from both organisations and local GPs. The service covers all disciplines including blood transfusion, biochemistry, haematology, immunology, microbiology, histopathology and cytopathology.  introduced a nurse led PICC line service which is overseen by Consultant Radiologist and delivered on some days by the radiology nursing team - this has freed up consultant radiologist capacity.  actively engaged with the Royal College of Anaesthetists (RCoA) Anaesthesia Clinical Services Accreditation Scheme (ACSA) allied to the Healthcare Quality Improvement Partnership.  designed a rota to cover the anaesthetic novice period when new doctors start in August until November saving £86k in 2017/18 rotation.  member of the ‘Trailblazer group’ developing the National Standard for ODP apprenticeships.  development of a programme for theatre staff, focussing on ‘Leadership for the Team Leaders and Deputies’ and trust values and behaviours for the rest of the team.  created a centralised Inpatient ‘Waiting List Team’ to manage all theatre bookings with teams focused on specialty requirements; effectiveness is monitored through a theatre performance dashboard.

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 regional service for navigated hip resurfacing surgical technique to reduce bone loss at hip arthroplasty.  introduction of a ‘Fragility Nurse Service’ and joint care model with a surgeon and geriatrician has contributed significantly to the being fifth in the country for fracture neck of femur outcomes.  the Bradford Macula Centre opened in 2017, a dedicated service which has reduced the waiting list for macular patients and patients surveys report excellent care.

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Maternity

Facts and data about this service

The trust has 80 maternity beds, all within Bradford Royal Infirmary. These beds are based across three wards and the birth centre.

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

From July 2016 to June 2017, there were 5,800 deliveries at the trust.

A comparison from the number of births at the trust and the national totals over the most recent 12 months are shown below.

Number of babies delivered at Bradford Teaching Hospitals NHS Foundation Trust – Comparison with other trusts in England

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A profile of all deliveries from July 2016 to June 2017 can be viewed below.

Table 1: Profile of all deliveries (July 2016 to June 2017) Bradford Teaching Hospitals NHS Foundation Trust England

Deliveries (n) Deliveries (%) Deliveries (%) Single or multiple births Single 5,202 98.5% 98.5% Multiple 80 1.5% 1.5% Mother’s age Under 20 219 4.1% 3.2% 20-34 4,190 79.3% 75.0% 35-39 710 13.4% 17.8% 40+ 163 3.1% 3.9% Total number of deliveries Total 5,282 608,950 Source: Hospital Episode Statistics Notes: A single birth includes any delivery where there is no indication of a multiple birth.

No gestation period data was recorded at the trust over this time period.

(Source: Hospital Episodes Statistics (HES) – Provided by CQC Outliers team)

The trend by quarter for the last two years can be seen in the graph below:

Number of deliveries at Bradford Teaching Hospitals NHS Foundation Trust by quarter

SOURCE: HES - Deliveries (July 2016 - June 2017)

During this inspection, we visited the labour ward, obstetric theatres, birth centre, antenatal ward (M3), and post-natal ward (M4) which includes a transitional care unit. We also visited the maternity assessment centre, antenatal clinic, and antenatal day unit. We spoke with 15 patients and relatives, and 46 members of staff. We observed staff delivering care, and looked at 10 patient records and 10 prescription charts. We reviewed trust policies and

20171116 900885 Post-inspection Evidence appendix template v3 Page 159 performance information from, and about, the trust. We received comments from patients and members of the public, who contacted us directly to tell us about their experiences.

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 trust set targets of 75% or 95% on a course by course basis for the completion of mandatory training.

A breakdown of compliance for mandatory courses from April 2016 to March 2017 for nursing/midwifery staff in maternity is shown below. All staff were based at Bradford Royal Infirmary.

Nursing and midwifery staff

Staff Staff Completio Trust Target Course title trained eligible n rate Target met? Corporate Induction 215 215 100% 95% Yes NEWS/PAWS/NeoNate Observation Theory - General 17 17 100% 75% Yes Infection Control - No Renewal 215 215 100% 95% Yes Communication Improvement using the SBAR Technique - General 213 214 100% 75% Yes Introduction to Equality & Diversity - General 208 215 97% 95% Yes Venous Thromboembolism - No Renewal 190 212 90% 75% Yes Diabetes Care and Safe Use of Insulin - General 182 211 86% 75% Yes Information Governance - 1 Year 184 215 86% 95% No Infection Control - 1 Year 181 215 84% 95% No Adult Basic Life Support - 1 Year 157 214 73% 75% No Fire Safety - 1 Year 155 215 72% 95% No Conflict Resolution - 3 Years 153 214 71% 95% No Blood Transfusion - 1 Year 121 170 71% 75% No Moving & Handling Low Risk - General 137 215 64% 95% No Health and Safety - 2 Years 136 215 63% 95% No Safe Administration of Medicines - Competence Assessment - General 115 196 59% 75% No Organising Receipt of Blood - 3 Year 73 139 53% 75% No Moving & Handling Medium/High Risk - General 99 205 48% 95% No Preparing to Administer/Administering Blood - 3 Year 76 168 45% 75% No

Safe Administration of Medicines - 2 Year 95 213 45% 75% No

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Collecting Blood Competency Assessment - 2 Year 59 164 36% 75% No NEWS/PAWS/NeoNate Observation Competence Assessment - General 2 17 12% 75% No

The overall completion rate for nursing and midwifery staff in maternity was 73%. The trust failed to meet their target for 15 of the 22 courses.

(Source: Routine Provider Information Request (RPIR) – P16 Total numbers – Planned vs actual tab)

A new obstetric mandatory training initiative had recently launched. The training was planned to take place over three days. The programme included trust mandatory training, and training around obstetric emergencies and key subjects. However, the first training session was cancelled due to lack of uptake.

In October 2017, PROMPT training replaced skills days. PROMPT training is evidenced based practice learning for obstetric emergencies and covers a variety of topics; including sepsis, shoulder dystocia, team working, and human factors training. Compliance rates from December 2017 were 81% for midwifery staff and 94% for medical staff.

Community midwives undertook community skills days, where they ran obstetric skills drills in each other’s houses. Staff told us this made training scenarios more true to life, as they were run in the home environment.

Individual staff and their managers had responsibility to book themselves on training. There was a practice development midwife in post who had oversight of staff training. Staff identified capacity within the service was a challenge, and several reported training being cancelled due to staffing shortages.

Some areas of training had particularly low compliance rates, such as, moving and handling training (48%) and training related to blood transfusions (36-53%).

Mandatory training had been on the maternity risk register since April 2016. The risk was reviewed in November 2017 and the service planned to have a single measure for training compliance, to allow it to be tracked more easily.

It was noted that mandatory training had been suspended for a period of time leading up to the implementation of electronic patient records in September 2017. This was due to the additional training needed for staff.

Safeguarding The trust set a target of 95% for the completion of safeguarding training.

A breakdown of compliance for safeguarding courses from April 2016 to March 2017 for nursing/midwifery staff in maternity is shown below. All staff were based at Bradford Royal Infirmary. Nursing and midwifery staff

Staff Staff Completio Trust Target Course title trained eligible n rate Target met? Safeguarding Children Level 2 - 3 Years 215 215 100% 95% Yes Safeguarding Children Level 1 - 3 Years 215 215 100% 95% Yes

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Safeguarding Adults Level 1 - 3 Years 212 215 99% 95% Yes Safeguarding Adults Level 2 - 3 Years 211 215 98% 95% Yes Safeguarding Children Level 3 - 1 Year 168 208 81% 95% No Safeguarding Children Level 3 Specialist - 1 Year- General 20 29 69% 95% No

The overall completion rate for nursing and midwifery staff was 95%. The trust failed to meet their target for two of the six courses.

(Source: Routine Provider Information Request (RPIR) – P16 Total numbers – Planned vs actual tab)

There was a specialist midwife for safeguarding who delivered mandatory training to staff. The training incorporated scenarios and case studies from recent events and current issues. The specialist midwife reviewed incidents related to safeguarding to further inform training.

A second person was being seconded to provide additional support to the existing safeguarding midwife. It was hoped this would allow them to focus on the more strategic elements of the role. Part of this would be further developing links with the Multi-Agency Risk Assessment Conference (MARAC); a victim focused information sharing and risk management meeting attended by key agencies, where high risk cases are discussed. The role of the MARAC is to facilitate, monitor and evaluate effective information sharing to enable appropriate actions to be taken.

The safeguarding midwife helped to establish the Yorkshire and Humber named midwives forum to address isolation for midwives in these specialist roles. The forum was designed to share good practice and provide peer supervision.

Midwives were encouraged to attend Bradford safeguarding children’s board, who also provided training.

Trust protocols and guidance on safeguarding were easily accessible. All band 7 midwives were trained to level 3 and experienced in knowing which pathways to follow. All staff we spoke with could describe what the process was if they had concerns. Staff identified or were made aware of safeguarding concerns on a regular basis and felt very experienced managing safeguarding situations. Data from the trust identified that in 2017 almost 10% of all women using the service had a safeguarding referral sent.

Safeguarding records were frequently updated and information could be added to the discharge summary. The midwives described good working relations with community midwives over safeguarding concerns, stating often they called their community colleagues to share information.

We were told about the Opal team, who had been in place for two years following additional funding. Commissioned by Better Start Bradford, the team has a reduced caseload, allowing them to provide enhanced care to vulnerable women.

Since September 2014, it has been mandatory for all acute trusts to provide a monthly report to the Department of Health and Social Care detailing the number of patients who have experienced female genital mutilation (FGM), or who have a family history of FGM. This information was collated by the safeguarding midwife.

Staff felt confident about reporting concerns around FGM, stating it would usually be identified during antenatal checks or on the labour ward. If found, a referral would be made to children’s social care services alongside mandatory reporting processes.

There was a process in place in the event of a baby being abducted. The baby abduction drill

20171116 900885 Post-inspection Evidence appendix template v3 Page 162 was included in the induction list for new starters; however, the policy that supported this was past its review date (2015). An abduction drill had been undertaken in February 2017. Some technical issues were identified in relation to the ‘lock down’ function; other feedback was that the flow chart needed to be simplified. The learning and subsequent changes from this exercise had not been actioned by the time of our inspection. This was discussed with the trust and immediate action was taken. A baby abduction risk assessment was completed and learning from this included in the updated policy. Two further abduction drills were also run from different locations within maternity within a week of the inspection.

Cleanliness, infection control and hygiene Divisional reporting of audit data was done each month and discussed at the infection prevention and control committee. This included areas such as hand hygiene, dress code, and insertion of peripheral cannulas.

We reviewed data from August, October and November 2017; and it was noted there were gaps where audit data had not been submitted. For example, the birth centre had not submitted data for the hand hygiene audit in August and September 2017, and ward M3 had not submitted data for September and November 2017. Omissions were recorded in the infection prevention and control committee minutes, which detailed that this was being followed up.

The results of hand hygiene and dress code audits were displayed in ward areas. For example, in the maternity assessment centre 100% compliance had been achieved for November and December 2017.

There had been no recorded cases of Methicillin-Resistant Staphylococcus Aureus (MRSA) or Clostridium Difficile within obstetrics in the last 12 months.

Single rooms were available in all areas for the isolation of patients, if needed. We observed appropriate signage and precautions being used for a patient requiring isolation.

The clinical areas we inspected were visibly clean. Hand towel and soap dispensers were adequately stocked. There was a sufficient number of hand wash sinks with hand washing technique signs. Hand gels were located at entrances with signs encouraging their use, and throughout clinical areas.

In the 2017 CQC Maternity Survey, the trust scored 8.2 for the cleanliness of rooms and wards. This was similar to the England average.

Personal protective equipment (PPE) was available in all areas we visited and provided to all staff in the community. We observed appropriate use of PPE during our inspection.

All staff we met adhered to arms bare below elbows guidance; however, we observed some staff wore rings with cut stones in them.

The trust had been commissioned to provide 200 flu vaccinations to patients. Midwifery staff felt this was positive, as they were capturing vulnerable women who may otherwise not have been vaccinated.

Environment and equipment The maternity areas were all co-located in a building separate to the main hospital. There were challenges with the layout of both the labour ward, birth centre, and antenatal and postnatal wards in complying with Health Building Note 09-02 – Maternity care facilities (2013). The guidance states that, “The reception desk should be located to enable all visitors entering or leaving the unit

20171116 900885 Post-inspection Evidence appendix template v3 Page 163 to be monitored”. However, this was not possible as the labour ward desk was located at the end of the entrance corridor, and slightly to the right. This meant that the entrance could not be seen from the reception desk. The reception desk for the birth centre and other wards was located along the wall, which meant staff would need to lean over the desk to gain a clear line of sight to the entry door.

There was a video call entry system in use for entry to both the labour ward, and birth centre and antenatal and postnatal wards; however, patients and relatives were able to exit without challenge by pressing a button next to the doors. Pressure blankets were used as an additional security measure, and the trust were looking to increase security through a baby tagging system.

During our inspection, we observed family members tailgating and entering the labour ward without challenge. Staff also informed us that family members would let relatives in after informing them of their arrival on mobile phones. This meant that staff could not be assured as to who was on the unit at any one time.

We discussed security with senior midwives who stated security was a concern; however, security concerns did not feature on the departmental risk register. We raised the issue with the senior management team, as further assurance was required.

A security baseline risk assessment was undertaken immediately following the inspection alongside the baby abduction risk assessment. Egress from the maternity wards was an area of particular concern and further assurance was requested concerning this. Again, a risk assessment was completed. Following this, we were provided with assurance that egress had been given serious consideration. An interim swipe exit measure was added to the existing swipe access, prior to the planned installation of a ‘speak and view system’ for exit, which was already in place to enter clinical areas. This was estimated to take two weeks to complete. As an additional measure, security guards were placed at exits to ensure clinical staff did not have to continuously leave patients to swipe people out. There were 12 delivery rooms on the labour ward, which all had access to en-suite facilities, although some were shared between two rooms. One room had a birth pool; however, there was no mobile hoist on the ward. Staff informed us that they had access to a hoist held in the birth centre. There were two obstetric theatres, which could be accessed directly from the labour ward and the birth centre. There was a two bedded recovery area adjacent to the theatres.

The Snowdrop bereavement suite was observed to be very clinical, and did not appear to have facilities for families to stay together. There was a kitchenette so families could make food and hot drinks. Access to the snowdrop suite was through the labour ward. Although the suite was set aside (between the birth centre and labour ward), staff and labouring women being transferred from the birth centre to the labour suite would need to pass the snowdrop suite. The bereavement service had the use of one cold cot, which enabled the baby to stay with the family whilst on the unit.

There were seven rooms in the birth centre. Two of the rooms had birth pools; however, only one pool had a ceiling hoist to evacuate women in an emergency. The other pool room had slings, and we were told staff had been instructed and had practices on how to use them.

The wards had a combination of bays and single rooms, with the transitional care unit located within the postnatal ward (M4). The maternity assessment centre and antenatal day unit had limited space. There were plans to look at how these areas could be expanded. Whist on site there we observed ongoing work to replace windows in the maternity building, which had been prone to leaking and letting in draughts.

We found the clean utility area on the labour ward was cluttered with boxes stored on the floor, and open instruments. We found a store cupboard, which was easily accessible to people on the

20171116 900885 Post-inspection Evidence appendix template v3 Page 164 unit, contained a box of paediatric emergency drugs. We removed these and gave them to senior staff. The dirty utility area was clean and well organised.

In the birth centre and on the wards, clean utilities were well organised and there were no items stored on the floor.

At the previous inspection, concerns had been identified in relation to the storage of milk. We did not find any concerns in relation to this and there was a flow chart in use for storage of breastmilk.

The emergency neonatal trolley was kept in the birth centre and was checked daily by the neonatal team in case of an emergency. There was one emergency resuscitation trolley available for the maternity assessment centre, labour ward, obstetric theatres, and the birth centre. This trolley was stored in the two bedded recovery room. We were concerned about the amount of time it might take to get the trolley from there to other areas. We asked staff about this, but there had been no issues or delays in relation to this.

We found daily emergency resuscitation trolley checks were not always completed, which was not in line with trust policy. Gaps in checking emergency equipment were found at the previous inspection in 2016. During this inspection, we found the checks on the trolley also did not correlate with the checks recorded by the labour ward coordinator on the safety checklist sheet.

Between 1st November 2017 and 9th January 2018, we found the emergency resuscitation trolley had not had a daily check on 23 occasions. On ward M3 and M4, we noted a few occasions when checks had not been completed. Staff informed us that they were required to fully open the trolley and check the entire contents on a daily basis. Staff said this took a significant amount of time. We checked resuscitaires on the labour ward and in the birth centre and found that generally checks had been undertaken. However, the document was a single check box and did not identify individual checks to be made.

Wards M3 and M4 had trolleys with the necessary equipment to manage a postpartum haemorrhage (PPH). We could not find a checklist to indicate daily checks had been undertaken. This was highlighted to staff, and before we had left the department, checklists were in place.

There were two fetal blood analysis machines. We saw information clearly displayed on the seven stages to improve sample quality for fetal blood samples. Staff could not provide assurance that these had been checked daily. Biochemistry lab representatives did daily quality control the machines; however, there was no documentation on the labour ward to identify these checks had been undertaken.

There was adequate equipment in the areas we visited to meet patient’s needs. This included a variety of equipment for women to use in labour. Specialist equipment was available for women with a high body mass index (BMI) when required. We checked various pieces of equipment for evidence of in date electrical testing stickers. This had been highlighted as an area for improvement at the previous inspection. We found these to be in place and in date on all the equipment checked. Community midwives carried their own class three baby scales, which were calibrated annually. Assessing and responding to patient risk A modified early warning score (MEWS) tool was used in maternity. This assessment tool enabled early identification of women who required additional medical support or closer monitoring. In the 10 sets of records we reviewed, we found these had been accurately completed, with any raised scores escalated.

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An audit of MEWS scores was undertaken across three areas: M3, M4, and the labour ward; 45 charts completed between March and April 2017were reviewed. The audit identified some inconsistencies in the completion of MEWS scores. For example, a minimum of 12 hourly MEWS recording for stable patients. Some charts showed this was being done more frequently, and a small number less so. The findings from the audit and related actions were to be discussed at the quality and safety core group in February 2018.

We saw the use of the sepsis bundle in patient records. The sepsis bundle is a group of medical interventions to treat patients with a serious infection. Training was provided on sepsis as part of the PROMPT training days.

At our previous inspection, staff reported there had been issues in terms of escalation. The process had been improved with the labour ward coordinator being identified as a central point of contact. They would liaise directly with obstetric staff. Most staff reported feeling happy to escalate concerns, but if they did not feel able to challenge the doctors, that they would go to the coordinator. Medical staff also reported the escalation process worked well. Copies of the standard operating policy for escalation of clinical concerns were seen in clinical areas.

We observed a situation in theatre with a baby deteriorating; the situation was managed calmly with good team working observed. Staff reported that undiagnosed breeches were managed well as obstetricians had a lot of experience in this area.

There was on site access to neonatal and adult intensive care beds. There were clear processes in place if a transfer to either unit was required, and staff reported this worked well.

Risk assessment at antenatal booking was done for all women using trust guidance to determine whether individuals were high or low risk. Midwives also completed venous thromboembolism (VTE) risk assessments.

There were consultants who had special interests and provided support for women who had conditions such as diabetes or epilepsy. There was also a number of specialist midwifes who could provide support in areas such as smoking cessation.

We observed the triage system in the maternity assessment centre (MAC). All women who reported reduced fetal movements were asked to attend. We observed an advice folder, which contained information such as; care plans for women who were high risk, and what to do if they contacted MAC.

The MAC was a busy unit, and the midwives often felt they were left as the decision makers when it was approaching time for the unit to close. They also stated that decisions over care were frequently rushed, as there was pressure to move women through the department. We did not find any evidence of harm because of this.

The World Health Organisation (WHO) devised a safer surgery checklist, which includes steps to be completed when anyone has an operation. This was adapted to include obstetric procedures in 2010. Four of the records we reviewed contained a WHO checklist and we found these had been fully completed. However, when we observed these steps in the obstetric theatre, we saw that whilst each stage was completed, the process was not embedded and we did not observe active engagement from all team members. For example, at the sign in stage, the patient’s identification band was not checked and the registrar left theatre before the sign out was completed.

We were provided with audit data from February 2017, which looked at 61 cases. It was found WHO checklists were not used in 30% of category one caesarean sections. Areas for improvement were identified, such as, simplifying the WHO checklist form and displaying more

20171116 900885 Post-inspection Evidence appendix template v3 Page 166 posters/reminders for staff. We were provided with information that a re-audit in December 2017 found compliance overall had improved to 89%; however, details of the audit itself were not provided.

The audit results were presented to the patient safety committee. We were concerned that barriers to completing WHO safety checks were identified as; junior staff not used to working in theatres, staff being distracted by other tasks and documentation, and staff being too busy because of a fast turnover, especially out of hours. These are situations where the completion of such checks becomes even more important to maintain patient safety. Whilst the re-audit showed some improvement, the ongoing action of ‘encourage whole team to prompt/complete WHO checklist depending on availability’, was not felt to be a strong enough message to staff. In addition, the audit process was a review of completed forms and did not involve observing the quality of the safety checks. It is, however, important to note that there have been no incidents reported as a result of these checks not being completed. Midwifery and nurse staffing Midwifery staffing

The trust has reported the following staffing numbers for maternity as at September 2017:

Ward/Site Planned staff (WTE) Number in post (WTE) Bradford Royal Infirmary 220 212

(Source: Routine Provider Information Return (RPIR) – P16 Total numbers – Planned vs actual tab)

The following staffing information is routinely requested within the universal provider information request spreadsheets, to be completed within a standard template. All staff were based at Bradford Royal Infirmary.

Vacancy rates

From October 2017 to September 2017, Bradford Royal Infirmary reported a vacancy rate of 11% in maternity. The trust has set no target vacancy rate.

(Source: Routine Provider Information Request (RPIR) P17 Vacancies)

Turnover rates

The trust did not provide any turnover data for nursing and midwifery staff in maternity.

Sickness rates

The trust did not provide any sickness data for nursing and midwifery staff in maternity.

Bank and agency staff usage

Please note that we have been unable to calculate bank and agency usage as a proportion of the total number of shifts available including those covered by permanent staff due to the fact that the total number of bank and agency shifts reported by the trust was often higher than the total number of available shifts.

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From October 2016 to September 2017, the trust reported bank usage for nursing staff in maternity of 1,460 shifts and agency usage of one shift. There were 543 shifts that were unfilled by bank and agency staff. All of these shifts were at Bradford Royal Infirmary.

(Source: Routine Provider Information Request (RPIR) P20 Nursing – Bank and Agency)

Midwife to birth ratio

The Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in Labour set by the Royal College of Obstetricians and Gynaecologists (RCOG), recommend a ratio of 1:28. This being one midwife to 28 births. As of June 2017 the trust had a ratio of one midwife to every 26.5 births. This is better than the England average. Monthly information on the midwife to birth ratio was included in the maternity dashboard. The most recent figures from December 2017 gave a ratio of one midwife to 29.1 births.

(Source: Electronic Staff Records – ESR Data Warehouse)

Red Flag maternity staffing guidance was updated by NICE in December 2017, and explains what signs may indicate there are not enough midwives available. For example, a delay of two hours or more between a woman coming in for induction of labour and the process being started. This system was not used by the trust.

The service had last used Birth Rate Plus (a midwifery workforce planning tool) in May 2017. The recent review identified a requirement for a further 15.87 whole time equivalent (WTE) midwives within the maternity unit. It also recommended an increase of 13.58 WTE within community midwifery teams. Whilst the trust acknowledged the pressures within community teams, it was felt to be less of an acute problem. There were plans to increase staffing on the MAC to allow this to be a 24/7 service. This would positively affect community team’s workload, and reduce the number of women not in labour admitted to the labour ward after the MAC closed on an evening.

Midwifery staffing was on the departmental risk register. The trust was in the process of recruiting an obstetric theatre team, which would account for 6.18 WTE of the recommended staffing uplift. At the time of inspection, if a woman had to go to theatre for an emergency caesarean section then a midwife would act as scrub practitioner with a second midwife in attendance. When this occurred, it had a significant impact on the agreed establishment of eight midwives on the labour ward.

Two band 7 coordinators were available per shift to support staff on the labour ward. We were informed one of these was not included in staffing numbers, to allow them to function in a supervisory capacity. On the two days we visited the labour ward, we found that this was not the case, and the coordinators were providing direct care for two women as well as fulfilling their coordinator role.

We reviewed a week’s rota on the labour ward and found most shifts had the agreed eight midwives on duty, but we noted three shifts where there were only seven. During our inspection, we inspected the labour ward when there were seven midwives on duty and one of them was in theatre. There were three midwives, each caring for two women. One of the midwife’s was caring for a mother who had experienced the loss of a baby, as well as a woman with sepsis. Another midwife was caring for two women both having induction of labour. They stated one would be reallocated to another midwife if the second woman went in to labour. However, we lacked assurance that there were enough midwives to facilitate this.

Planned staffing levels were not achieved in the birth centre during our inspection; they were short of one midwife for both the early and late shift. To mitigate this, two beds had been closed.

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All of the staff we spoke with highlighted midwifery staffing as a concern, and that the staffing establishments on the labour ward and birth centre were not sufficient to provide the level of care needed. Several said they did not feel they always provided sufficient one-to-one care for women in labour, and that they often missed breaks. We were told about a new standard operating policy that had been introduced to try to ensure breaks were taken.

Information was collected each month in the maternity dashboard on the percentage of women receiving one-to-one care during labour. The trust acknowledged that they were non-compliant with January 2015 NICE guidance Safe Midwifery Staffing for Maternity Settings, due to only being able to achieve 1:1 care for women in labour approximately 70% of the time.

The ‘hot desk’ midwife managed midwifery staffing Monday to Friday from 8am to 5pm. The rota for this role comprised of band 7 and specialist midwives. Their role was to manage constant changes in acuity in different areas. This involved staff being moved to different areas to manage staffing, often on a daily basis. The ‘hot desk’ midwife was the point of contact for escalation of any staffing issues.

An electronic rota system was used; any gaps were covered by rotating midwives to other areas, by bank staff or staff working additional shifts. For example, on M3 week commencing 20 February there were 20 unfilled shifts when the rota was produced, but these were all subsequently covered.

We observed handovers on wards M3 and M4 and the labour ward. The handovers were concise and provided detailed information about patient’s clinical conditions. Staff predominantly worked 12 hour shifts, with handovers taking place at the beginning and end of each shift.

We observed and spoke with volunteers who supported staff by answering telephones and assisting with non-clinical tasks.

Medical staffing The trust has reported the following medical staffing numbers for maternity as at September 2017:

Ward/Site Planned staff (WTE) Number in post (WTE) Bradford Royal Infirmary 41.7 41.2

(Source: Routine Provider Information Request (RPIR) – P16 Total numbers – Planned vs actual tab)

The following medical staffing information is routinely requested within the universal provider information request spreadsheets, to be completed within a standard template. All staff were based at Bradford Royal Infirmary.

Turnover rates The trust did not provide any turnover data for medical staff in maternity. This information will need to be requested during the inspection as part of standardised requests. Once this has been received we will be able to populate the analysis to complete this section.

(Source: Routine Provider Information Request (RPIR) P18 Turnover)

Sickness rates

The trust did not provide any sickness data for medical staff in maternity.

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(Source: Routine Provider Information Request (RPIR) P19 Sickness)

Bank and locum staff usage

Please note that we have been unable to calculate bank and locum usage as a proportion of the total number of shifts available including those covered by permanent staff due to the fact that the total number of bank and locum shifts reported by the trust was often higher than the total number of available shifts.

No data has been supplied by the trust pertaining to bank and locum usage for medical staff within maternity from October 2016 to September 2017.

(Source: Routine Provider Information Request (RPIR) P21 Medical Locums)

Staffing skill mix In August 2017, the proportion of consultant staff reported to be working at the trust was slightly higher than the England average and the proportion of junior (foundation year 1-2) staff was also higher than the England average.

This England Trust average Consultant 42% 40% Middle career^ 0% 8% Registrar group~ 48% 46% Junior* 10% 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)

Consultant cover on the labour ward was 98 hours per week, provided by 14 consultants on a ‘hot week’ basis, working a one in 14-week rota. The ‘hot week’ consultant was resident from 8.30am to 5.30pm Monday to Friday. The on call consultant provided resident cover from 5pm to 10pm Monday to Friday and 8am to 10pm at weekends. They were then on call from home. There was 24-hour availability of an anaesthetist.

The maternity assessment centre had a senior house officer until 5pm, after which the registrar on call on the labour ward could be contacted if a doctor was required. There was an escalation policy for getting medical help, and a laminated copy for in and out of hours was displayed in the office.

The on call consultant had a number of areas to cover and the workload could be challenging. Consultants told us the intensity of work was sometimes difficult to manage, as they can be pulled in different directions. However, colleagues were able and willing to help.

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On two of the days we visited labour ward, the ‘hot week’ consultant was also covering the elective caesarean section theatre list, as there was no locum. The consultant had discussed this with the labour ward co-ordinator and felt the level of activity on labour ward allowed this duel cover. We observed the safety huddle on one of these days and it was mentioned that because of this duel cover the ward round had been delayed.

Daily ward rounds took place in each area. On the postnatal ward, we noted ward rounds started whilst the midwives were in handover. This meant night staff started on the ward round, and then the day staff took over once handover was complete. This felt a little disjointed; some midwives commented on this, but were not aware of any plans to review the timing of ward rounds.

Several of the doctors we spoke with also identified pressures when working in the antenatal clinic, primarily due to the doctor to patient ratio. We were told four patients were booked in to two patient slots, meaning clinics overran and left limited time for decision-making. We were also told clinics were not cancelled when consultants were away. On the day we visited 31 women had been booked into one clinic. A survey had been undertaken on these issues and we were informed a review project had commenced. We requested details of this work, but they could not be provided.

Records The trust had implemented a trust-wide electronic patient record (EPR) in September 2017. Maternity were only using elements of this alongside the Medway EPR. In addition, there were paper records for intrapartum care. Although much of the information was recorded electronically, handheld notes were carried by women throughout pregnancy in line with National Institute for Health and Care Excellence (NICE) Quality Standard (QS), statement 3. Paper records were stored securely and access to EPR was limited to designated staff.

The combination of records used caused some concern and most staff, both midwifery and medical, commented on how much time they spent completing records. We observed this during our inspection. This was particularly noted in MAC and the antenatal clinic, where there was a fast work pace, high turnover of patients, and considerable time constraints. In MAC, midwives also told us that they could not record admission of their own patients on the EPR system. The midwives had to contact the central admissions team for them to complete this task.

We reviewed 10 sets of patient records, and despite the challenges staff described, we found that records were generally clear and contained completed risk assessments and care plans. We did find some issues with paper records, such as notes that had been made on paper towels, and scraps of paper taped into medical records. We also observed the practice of notes being made on paper towels in theatre.

In a small number of records, we observed photocopies of observation charts were in use. The whole document had not been copied and the page with patient identifiable information had not been included. There was a risk that if this page came loose, it would not be known which patient record it belonged to. We also saw cardiology continuation sheets used in some medical notes, with cardiology crossed out and over written by obstetrics.

We raised the above issues with the trust and they informed us that making notes on paper towels or scraps of paper was a cultural legacy. An audit was undertaken in response of 33 records. No further incidents regarding the use of paper towels or other pieces of scrap paper were identified, but loose documents were found in 23% of the records reviewed. A further audit was planned for eight weeks’ time.

No regular documentation audit was in place. However, documentation would be reviewed as part of other audits, and evaluated at each case review and investigation. However, it was noted the

20171116 900885 Post-inspection Evidence appendix template v3 Page 171 records with paper towels taped in were subject to an investigation, and there was no mention of this in the investigation report.

Since the last inspection, advice sheets had been developed to record telephone advice given to women who contacted the ward either ante or postnatally. This information was held in a central file and not placed in individual patient records. We asked if this information could be stored electronically, so it was available if a woman contacted the wards again. We were told this was not currently possible.

Medicines Medicines were stored securely and access was restricted to authorised staff. Controlled drugs were appropriately stored and managed, and balance checks were carried out in accordance with the trust policy. The exception to this was the labour ward; between 1 November 2017 and 9 January 2018, we were unable to find evidence of checks on controlled drugs on ten occasions. We also found that wastage from epidural infusions was not being recorded. This had been found at the previous inspection.

We checked the storage and monitoring of medicines requiring refrigeration and found this was not always carried out in accordance with trust policy and national guidance. For example, on ward M3 temperatures had been recorded which were higher than the recommended range on six days in January 2018, and no action had been recorded on the monitoring form. In addition, staff had failed to record temperatures on seven days in December 2017.

We reviewed 10 patient records. In four of these, we found staff had not always recorded the reason why medicines had been delayed or omitted. This meant we could not be sure patients were receiving their prescribed medications as intended. The trust audited delayed and omitted doses, but the latest audit provided (December 2017) did not detail any plans to reduce these omissions.

There was no record of whether medicines reconciliation had been completed for the 10 records we reviewed. The maternity wards did not receive a clinical pharmacy service.

Patient Group Directions (PGDs) were in use in maternity. However, staff referred to paper copies kept on the wards, which were past their date of review, rather than accessing up-to-date electronic versions available on the trust intranet. PGDs are written instructions that allow specified healthcare professionals to supply or administer a particular medicine in the absence of a written prescription. We checked three PGDs and found the clinical co-ordinator did not have an up-to-date record of staff signatures for each medicine. This meant there was a risk some staff were administering medicines without the proper legal authorisation in place.

Incidents Never Events

Never events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. 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 2016 to October 2017, the trust reported no incidents which were classified as never events for maternity.

(Source: NHS Improvement – STEIS (01/11/2016 - 31/10/2017))

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Breakdown of serious incidents reported to STEIS

In accordance with the Serious Incident Framework 2015, the trust reported six serious incidents (SIs) in maternity which met the reporting criteria set by NHS England from November 2016 to October 2017.

Of these, the most common types of incident reported were:

 Maternity/Obstetric incident meeting SI criteria: mother and baby (this include foetus, neonate and infant) with three (50% of total incidents).  Maternity/Obstetric incident meeting SI criteria: baby only (this include foetus, neonate and infant) with two (33% of total incidents).  Treatment delay meeting SI criteria with one (17% of total incidents).

(Source: NHS Improvement – STEIS (01/11/2016 - 31/10/2017))

Incidents were reported on an electronic system. All staff we spoke were aware of how to report incidents and gave examples of what types of things they would report. The exceptions to this were three student midwives, who were not aware of how to report an incident. Community midwives were encouraged to report incidents as soon as possible after the event; however, mobile device connectivity problems meant that this was not always possible. In this case, staff were able to contact managers who would record the concerns on the electronic reporting system. Incidents were reviewed daily by matrons’ and taken to the weekly case review meeting, which took place on a Friday. The risk midwife introduced the meetings last year, to get immediate messages out to staff. If a more immediate safety concern was identified, then the head of midwifery would be informed who would inform the trust risk team. Those able to attend case review meetings fed back that the meetings had improved learning and made it seem more relevant. However, we identified that the majority of midwives were unable to attend meetings regularly, due to staffing numbers. Following the weekly meeting, a lessons learned newsletter was circulated, in addition to a monthly quality and safety newsletter. These gave summaries of serious incidents and identified any themes. Other methods were also used to share information, such as a closed social media group and notice boards. We were also told a debrief was held for complex cases. We saw sharing of learning in a staff information file in MAC, which advised staff what to do if a particular individual attended. The file contained a copy of the lessons learnt from the weekly incident case review; this included information on acute kidney injury and an information governance breach. Themes and trends were identified which included pressure areas, induction of labour, and managing violence and aggression. This document identified that it was to be discussed at handover and ward meetings.

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Despite these systems for sharing learning, the feedback we got from community and hospital midwives in relation to incidents was limited. Very few were able to articulate any learning from incidents and several were not aware of any recent serious incidents in maternity. Medical staff were generally able to tell us themes of incidents, such as shoulder dystocia and sepsis. They also reported serious incidents were openly discussed at governance meetings. We requested ward meeting minutes for the previous three months. No minutes were provided for the labour ward or the birth centre. Wards M3 and M4 had joint meetings, but the most recent minutes were from July 2017. One set of minutes was provided from the MAC team meeting in December 2017. With the exception of MAC, meeting attendance was very poor with numbers ranging from three to seven staff. Risk was a standing agenda item on ward M3 and M4 minutes, but not on MAC minutes. The level of detail was variable and no themes or trends were identified. We saw limited evidence of the lessons learned newsletter discussed in the minutes we reviewed. We observed four handovers, and noted key messages were given at the start, but these were not specifically about incident themes or risk. This was felt to be a missed opportunity to share learning. We attended the maternity unit daily safety huddle, where there was attendance from each area. This was felt to be more of a capacity and staffing meeting. Individual areas had been encouraged to implement safety huddles, but this was not embedded. Safety huddles were an integral part of the risk investigation and management flow chart process. However, staff reported they were generally too busy, so they often did not happen. Information provided to us stated there were risk champions in each area. Staff did not seem aware of this and we did not meet any during our inspection. We were told there had been themes of incidents around large numbers of visitors, who at times could be challenging and aggressive. Midwives were not aware of any action plan to directly address this; however, the actions taken after the inspection in relation to security would indirectly influence this. A number of staff told us they felt there were times when patient care was compromised as a direct consequence of staffing numbers. Whilst some said they would complete an incident form if this situation arose, many said they would not; due to the high frequency it occurred. For example, when one-to-one care could not be provided during labour, or when induction of labour was delayed. During our inspection, we observed some delays in care due to staffing shortfalls that were not reported as incidents; they were, however, highlighted to those in charge. For example, on ward M4 there had only been one midwife on duty overnight, and consequently, a blood transfusion had not been given to a woman with a low blood count. This had been delayed from the day before, as there were no staff on duty trained to give a blood transfusion. During a handover, staff reported they had planned to put a woman on cardiotocography (CTG) monitoring but were unable to do so due to a member of staff going home sick. We reviewed the investigation reports for two of the serious incidents. It was felt that these could have been more robust in terms of actions and recognition of areas for possible learning. For example, in one of the 72 hour reviews there were no recommendations made. The trust reported all births between 22+0 and 23+6 weeks gestation to the Maternal, New born and Infant Clinical Outcome Review Programme (MBRRACE). Perinatal mortality meetings were held most months. We reviewed meeting minutes, which evidenced discussions about individual cases. However, almost every case stated no lessons to be learnt. The duty of candour is a regulatory duty that relates to openness and transparency and 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. Staff were generally aware of the duty of candour, and spoke about being open and honest with patients. Following a

20171116 900885 Post-inspection Evidence appendix template v3 Page 174 significant incident, women and their families would be invited to attend a meeting to discuss what had happened. Senior staff were responsible for the formal duty of candour process.

Safety thermometer The maternity safety thermometer is a local improvement tool for measuring, monitoring and analysing patient harm and harm-free care. This was in use and data was collected each month on perineal and abdominal trauma; post-partum haemorrhage; infection; separation from baby; and psychological safety each month. However, this information was not displayed in any of the areas we visited. Data from the graph below shows that from February 2017 to December 2017, there were three months where the level of harm free care was better than the England average.

Bradford Teaching Hospitals NHS Foundation Trust, Maternity dashboard

(Source NHS Improvement 2014-2017)

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Is the service effective? Evidence-based care and treatment The care and treatment provided to women was based on guidance from the National Institute for Health and Care Excellence (NICE), Royal College of Obstetricians and Gynaecologists (RCOG), and evidence based practice. Policies and guidance could be accessed on the trust intranet which was easy to navigate.

Part of the maternity service improvement plan related to reviewing guidelines and the external references within them to ensure they reflected current practice. This was marked as a completed action in November 2017. Obstetric guidelines were also monitored monthly on the maternity dashboard with a target set of above 90% compliance. Figures from December 2017 reported a compliance rate of 83%. We reviewed 17 policies and found eight to be past their date for review. For example, hypoglycaemia of the newborn was due for review in March 2017, and the policy for severely ill pregnant women in June 2016.

This was identified at the previous inspection and raised with the trust during this inspection. The trust was aware of the issue and reported each policy was with the author awaiting review. However, this was a concern, as some policies were several months past their review date. This meant staff may not be using the most up to date guidance to inform their practice. We were also concerned that in four serious incidents reviewed it was noted that trust guidance had not been followed.

Staff were informed of any policy updates via the monthly quality and safety newsletter. There were nominated individuals who had responsibility for reviewing any new or updated NICE guidance. Any changes in practice had to be approved by the clinical effectiveness committee. We saw references to this in the minutes of the women’s services core group quality and safety meetings.

The trust had implemented the national stillbirth care bundle and used standardised symphyseal growth charts. An informed decision had been made not to use customised growth charts due to a lack of sufficient evidence. The two clinical commissioning groups (CCG’s) in Bradford supported this decision. However, conflicting information was provided as the trusts fetal growth and Doppler guideline stated, “At a regional level the Yorkshire and the Humber LSA and the regional Maternity Forum have agreed to support the introduction of customised growth charts and improve training and education relating to the assessment of fetal growth and wellbeing”.

The still birth compliance care bundle also stated that, customised antenatal growth charts were in use for all pregnant women by clinicians who had gained competence in their use, from December 2017. However, section two of the regional maternity submission from November 2017 (identification and surveillance of pregnancies with fetal growth restriction), asks, “Are you carrying out any activity to detect fetal growth restriction?” The next question asks, does it include making use of customised or standardised growth charts for all pregnant women by clinicians who have gained competence in their use?” Further, it asks, “to what extend have you implemented this activity?” The trust response was not at all.

Further information was requested to provide assurance over the decision not to use customised growth charts. We were provided with audit data from July 2017. This looked at the antenatal management of women and if they had been correctly risk assessed and appropriately identified as having babies which were small for gestational age. The audit of 40 women demonstrated a detection rate of 60%. The conclusion of this audit was that the trust detection rate of 60% was better than the national average.

Reduced fetal movements were another area of focus for the service. The trust was in the first

20171116 900885 Post-inspection Evidence appendix template v3 Page 176 wave of the maternity and neonatal health and safety collaborative, which was due to commence later in the year. This is a three-year programme to support the improvement of quality and safety. One of the work streams within this was reduced fetal movements. Challenges had been identified amongst some population groups where there appeared to be a delay in presentation. Audits and risk assessments were planned, as well as developing links with the local community to get key messages to women.

We found enhanced recovery pathways were in place for those undergoing an elective caesarean section.

Episcissors were in use; these are scissors with a 60-degree angle blade to reduce the margin for error when staff estimate the angle for cutting during an episiotomy. We observed staff being reminded to use these during a handover.

The ‘fresh eyes’ approach was used for review of CTGs. Stickers were available using a traffic light system, green indicating a normal trace, yellow to indicate a non-reassuring trace, and red for abnormal. We did not see consistent use of these stickers in the notes we reviewed.

‘Fresh eyes’ was included as part of the CTG audit proforma. This audit was undertaken on alternate weeks in response to the findings from serious incidents to provide assurance around CGT monitoring. We were provided with data from 30 sets of records from 6 December 2017 to 16 January 2018. This showed that CTG’s were being reviewed every hour in 75% of records and that ‘fresh eyes’ was undertaken in only 39% of records.

In response to this, a further 18 records were reviewed on the 22 January 2018. This identified that 85% of records had ‘fresh eyes’ undertaken. However, it was noted that the time frame for this was within 70 minutes and not within the recommended 60 minutes.

One of the elements in the still birth reduction care bundle related to a system being in place to provide ‘fresh eyes’. This had been updated in December 2017 and had been RAG rated green, indicating a system was in place. Part of the role of the coordinator was to be the second person to review CTG’s. We lacked assurance over their oversight and ability to fulfil this role as they were not always in a supernumerary capacity. This is reflected in the services compliance with ‘fresh eyes’ review.

Nutrition and hydration Meals were provided in the inpatient areas by a menu ordering system. Meals were available for different dietary requirements. On the antenatal and postnatal wards, meals were provided from a trolley and could then be taken by women to their own room if preferred.

Patients who had recently given birth told us they were offered tea and toast and hot and cold drinks were available 24 hours, seven days a week.

The unit had a breastfeeding initiation rate of 71% (December 2017); this is worse than the England average of 81%. Breastfeeding support was provided in line with the United Nations children’s fund baby friendly initiative (UNICEF BFI) guidelines. The service was first fully accredited in 2004, and due for reassessment in 2018. There were two specialist midwives for infant feeding and we received positive feedback from women in relation to support for breastfeeding. Breast feeding support maps were displayed in patient areas, detailing contact details for support groups in different areas of the city.

We spoke with a mother who had been struggling with bottle-feeding; she was supported to try an alternative bottle, which baby accepted.

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Pain relief Women received information about the pain relief options available to them. These included Entonox (Nitrous Oxide and Oxygen) piped directly into all delivery rooms, and pharmacological methods, such as Diamorphine and Pethidine.

Anaesthetic cover was provided on the delivery suit 24 hours a day, and included an epidural service.

Women who chose to give birth at home had access to Entonox and Meptazinol (Meptid), an opioid analgesia; however, it is not classed as a controlled drug.

We saw evidence of pain scores on the observation charts we reviewed. The women we spoke with reported getting pain relief in a timely way. Patient outcomes National Neonatal Audit Programme

In the 2016 National Neonatal Audit the trust performance was as follows:

Do all babies of less than 32 weeks gestation have their temperature taken within an hour of birth?

Out of a sample size of 96 babies, 99% had their temperature taken within an hour of birth. This was better than the England average of 96%.

Are all mothers who deliver babies from 24 to 34 weeks gestation inclusive given any dose of antenatal steroids?

Out of a sample size of 178 babies, 94% were given a complete or incomplete dose of antenatal steroids. This was better than the England average of 86%

What proportion of babies < 33 weeks gestation at birth were receiving any of their own mother’s milk at discharge to home from a neonatal unit?

Out of a sample size of 82 babies, 61% were receiving their mother’s milk. This was better than the England average of 59%.

(Source: National Neonatal Audit Programme, Royal College of Physicians and Child Health)

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Standardised Caesarean section rates and modes of delivery

From July 2016 to June 2017 the total number of caesarean sections was as expected. The standardised caesarean section rate for elective sections was lower than the England average and the rate for emergency sections was similar.

Standardised caesarean section rates England Bradford Teaching Hospitals NHS Foundation Trust Type of Caesarean Caesareans Caesarean Standardised caesarean RAG rate (n) rate Ratio Elective Lower than 12.1% 433 8.2% 73.2 (z=-2.5) caesareans expected Emergency Similar to 15.4% 809 15.3% 101.0 (z=0.1) caesareans expected Similar to Total caesareans 27.5% 1,242 23.5% 89.2 (z=-1.6) expected Note: Standardisation is carried out to adjust for the age profile of women delivering at the trust and for the proportion of privately funded deliveries.

In relation to other modes of delivery from July 2016 to June 2017 the table below shows the proportions of deliveries recorded by method in comparison to the England average:

Proportions of deliveries by recorded delivery method Bradford Teaching Hospitals England Delivery method NHS Foundation Trust Deliveries (n) Deliveries (%) Deliveries (%) Total caesarean sections1 1,242 23.5% 27.5% Instrumental deliveries2 451 8.5% 12.5% Non-interventional deliveries3 3,579 67.8% 59.7% Other/unrecorded method of 10 0.2% 0.3% delivery 100% Total deliveries 5,282 100% (n=608,950)

¹Includes elective and emergency caesareans 2Includes forceps and ventouse (vacuum) deliveries 3Inlcudes breech and normal (non assisted) deliveries (Source: Hospital Episodes Statistics (HES) – provided by CQC Outliers team)

Normal vaginal deliveries were promoted, and the trust achieved a better than national average non-interventional delivery rate.

Maternity active outlier alerts

As of November 2017 the trust has no active maternity outliers. The last outlier alert, for significantly high elective caesarean sections, was closed after follow up of the trust’s action plan by the CQC inspection team in 2014.

(Source: Hospital Evidence Statistics (HES) – provided by CQC Outliers team)

Maternal, Newborn and Infant Clinical Outcome Review Programme (MBRRACE Audit)

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The trust took part in the 2017 MBRRACE audit and their stabilised and risk-adjusted extended perinatal mortality rate (per 1,000 births) was 7.01. The comparator group was 6.44. When compared to other trusts with similar service provision, the trust’s rate was in the amber band indicating that it was up to 10% higher than the average for the comparator group.

(Source: MBRRACE-UK)

From speaking with staff, we saw there were clear pathways for when an abnormality or concern was detected during antenatal care.

Over the previous year, the trust consistently reported a higher proportion of stillbirths compared to the regional average. Data from January 2017 to December 2017 showed monthly figures between 6.3% and 7.7%, compared to an average of 4.7%. Each case was discussed at monthly perinatal mortality meetings, and the stillbirth care bundle had been implemented to focus on specific areas to try and reduce this figure.

The trust was also flagging for the number of pre-term babies born before 37, 34 and 24 weeks. This was particularly noted for 34 weeks, with all but one month being higher than the regional average from January to December 2017.

In five of the months between January 2017 and December 2017, the trust was higher than the regional average for the number of term babies with a low birth weight.

Between January and December 2017, 1.4% (82) of the total number of live births were babies born before arrival (BBA) of a midwife. There was a peak of 12 BBA’s in March 2017. There was a policy in place that if babies were a planned homebirth the midwife would be called and mother and baby cared for at home. However, if the BBA was an unplanned home birth, both mother and baby would be brought to the unit by ambulance.

All the data mentioned above and additional indicators were collated in the maternity dashboard. This was updated each month to track and monitor patient outcomes. This information was shared at clinical incident panels, and a quarterly report was sent to the board. Competent staff Appraisal rates

From October 2016 to September 2017, 70% of staff within maternity at the trust had received an appraisal compared to a trust target of 100%. Please note that no appraisal data was provided for the medical and dental staff subgroup within maternity. A split by staff group can be seen below:

Appraisals Appraisals Appraisal Trust Target Staff group completed required rate Target met? Estates & Facilities 2 2 100.0% 100% Yes Admin & Clerical 28 40 70.0% 100% No Nursing & Midwifery registered 144 206 69.9% 100% No Additional Clinical Services 24 35 68.6% 100% No

(Source: Routine Provider Information Request (RPIR) P43 Appraisals)

Deputies were in the process of being appointed on ward M4. Part of their role would be to provide support with appraisals. Feedback from staff was positive about the appraisal process. The document used to guide and document appraisals was called ‘time to talk’, and staff felt it was a valuable process.

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There was a midwifery preceptorship document for newly registered staff, which outlined specific competencies and essential training for midwives.

The trust had maintained a supervision of midwifery team. Four staff had undergone the bridging programme to gain the Professional Midwifery Advocate (PMA) role. This new model of supervision was supported by NHS England and Health Education England. Four more staff were due to complete this training in February 2018, with a view to having formal sessions running by March 2018.

Student midwives we spoke with said they felt well supported, despite the staffing pressures. Midwives had gone through skills and drills training with them, for example, for the management of a post-partum haemorrhage.

CTG interpretation and training was delivered via the K2 training package. Training figures from December 2017 showed 100% compliance for medical staff and 95% for midwives. Bespoke training was also provided for staff on the management of third degree tears.

There were 10 specialist midwives covering areas such as, teenage pregnancy and smoking cessation. The specialist bereavement midwife facilitated a two-day training course for staff.

A perinatal mental health midwife had been added to the recent birth rate plus staffing review, as this was an identified gap. However, some experienced midwives within the team could also provide support in this area. There was also a consultant starting at the trust with an interest in perinatal mental health.

Multidisciplinary working Good multi-disciplinary (MDT) working was evident in clinical areas. There were close links with community staff on the maternity unit regarding safeguarding concerns and complex cases.

Midwives in the community worked closely with GPs and social care services when dealing with safeguarding concerns or child protection risks. The health visitors and the community midwife team worked together to identify and report potential risks to hospital staff. Risks were notified to health visitors, and community midwives had access to pathways about vulnerable women. The services worked with the perinatal mental health team based at a local trust. The team were planning visits to the trust to speak with midwives about mental health issues. We were provided with an example of a positive outcome for a mum with mental health needs through effective MDT working.

Specialist clinics were available for pregnant women who might require additional help or support, for example, if they had epilepsy. Staff confirmed they could access advice and guidance from specialist nurses/midwives, as well as other allied health professionals.

We observed ward rounds with midwifery and medical staff, and saw good communication and team working. On the labour ward, we observed the coordinator being regularly updated by staff and liaising with the obstetric team as required. Doctors fed back that the daily safety huddle was a good way of co-ordinating work.

Seven-day services Medical staff were available on the maternity unit ward 24 hours a day. Out of regular working hours, there was always a consultant available on call. There was consultant presence on site 98 hours per week, which equated to 14 hours a day.

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From the notes we reviewed, we found evidence of a daily consultant review.

There was access to dedicated obstetric theatres, and anaesthetic and theatre staff were available seven days a week. There was also access to critical care facilities at the trust.

The maternity assessment centre was open from 10am to 10pm Monday to Friday. It was hoped the staffing review would support a 24 hour seven days a week service.

Community midwives provided a seven-day service with antenatal clinics in community settings; all postnatal visits took place either in the home or local authority Sure Start buildings. Health promotion We saw information displayed in ward areas on topics such as, ‘what can we do to keep our pregnancy healthy and happy’; this gave advice on areas such as keeping active, cutting down on alcohol, and healthy eating. We also saw information on preventing pressure ulcers, and safer sleeping for babies.

There was a smoking cessation midwife in post; and we saw good informative posters displayed on this for women.

There was a specialist consultant for women with a raised body mass index.

The trust did not provide baby milk to try to encourage breast-feeding. This also meant that those who chose to bottle feed could be observed making up formula. Consent, Mental Capacity Act and Deprivation of Liberty Safeguards Mental Capacity Act and Deprivation of Liberty training completion

The trust reported that, from April 2016 to March 2017, Mental Capacity Act (MCA) training was completed by 95% of nursing staff within maternity. The trust target was 95% completion. All staff were based at Bradford Royal Infirmary.

The breakdown of course completion is shown below:

Nursing and midwifery staff

Staff Staff Completion Trust Target Course title trained eligible rate Target met? Mental Capacity Act Level 1 210 212 99% 95% Yes Mental Capacity Act Level 2 197 213 92% 95% No

(Source: Routine Provider Information Request (RPIR) P40 – Statutory and Mandatory Training)

The women we spoke with felt involved in their care and that they had been provided with sufficient information to make informed choices. Midwives were able to articulate how they would obtain informed consent prior to a procedure, either verbally or in writing. Staff spoke about the use of Gillick competency for consent of patients under the age of 16.

The most recent audit of consent was in September 2016, which looked at a total of 45 consent forms from obstetrics and gynaecology. Various aspects of the form were reviewed, such as, were risks identified and the appropriate form being used. Overall compliance was good with many

20171116 900885 Post-inspection Evidence appendix template v3 Page 182 areas achieving 100%. A re-audit was planned for September 2017; however, this did not take place due to EPR going live.

Community midwives had a process in place should a woman disclose mental health concerns. They used Whooley questions (a depression screening tool), which identified whether to engage other services, dependant on the woman’s score.

Is the service caring?

Compassionate care Friends and Family test performance

Friends and family test performance (antenatal), Bradford Teaching Hospitals NHS Foundation Trust

From October 2016 to September 2017 the trust’s maternity Friends and Family Test (antenatal) performance (% recommended) was generally slightly better than the England average. There was a notable decline in May 2017, which was rapidly rectified by July 2017.

Friends and family test performance (birth), Bradford Teaching Hospitals NHS Foundation Trust

From October 2016 to September 2017 the trust’s maternity Friends and Family Test (birth) performance (% recommended) was generally slightly better than the England average.

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Friends and family test performance (postnatal ward), Bradford Teaching Hospitals NHS Foundation Trust

From October 2016 to September 2017 the trust’s maternity Friends and Family Test (postnatal ward) performance (% recommended) was generally similar to the England average. The trust showed slight fluctuation but, despite this, performance was similar to the England average for the entire reporting period.

Friends and family test performance (postnatal community), Bradford Teaching Hospitals NHS Foundation Trust

From September 2016 to September 2017 the trust’s maternity Friends and Family Test (postnatal community) performance (% recommended) was generally similar to the England average. There is a sudden drop down to 0% in August 2017; this may indicate a failure in data collection.

(Source: NHS England Friends and Family Test)

CQC Survey of women’s experiences of maternity services 2017

The trust performed better than other trusts for three questions in the CQC maternity survey 2017, worse for one and similar to other trusts for the remaining 15 questions.

Area Question RAG Score At the very start of your labour, did you feel that you were given appropriate advice and support when you Better 9.5 contacted a midwife or the hospital? During your labour, were you able to move around and Worse 7.2 choose the position that made you most comfortable? Labour and Did you have skin to skin contact (baby naked, directly on birth your chest or tummy) with your baby shortly after the About the same 8.8 birth? I If your partner or someone else close to you was involved in your care during labour and birth, were they able to be About the same 9.7 involved as much as they wanted? Did the staff treating and examining you introduce Staff during Better 9.6 themselves? labour and Were you and/or your partner or a companion left alone birth About the same 7.5 by midwives or doctors at a time when it worried you? 20171116 900885 Post-inspection Evidence appendix template v3 Page 184

If you raised a concern during labour and birth, did you About the same 9.0 feel that it was taken seriously? If you needed attention during labour and birth, were you able to get a member of staff to help you within a About the same 9.3 reasonable time? Thinking about your care during labour and birth, were About the same 9.5 you spoken to in a way you could understand? Thinking about your care during labour and birth, were About the same 8.9 you involved enough in decisions about your care? Thinking about your care during labour and birth, were About the same 9.6 you treated with respect and dignity? Did you have confidence and trust in the staff caring for About the same 9.2 you during your labour and birth? Looking back, do you feel that the length of your stay in Better 8.2 hospital after the birth was appropriate? On the day you left hospital, was your discharge delayed About the same 5.9 for any reason? If you needed attention while you were in hospital after the birth, were you able to get a member of staff to help About the same 6.8 you within a reasonable time? Care in Thinking about the care you received in hospital after the hospital birth of your baby, were you given the information or About the same 8.0 after the explanations you needed? birth Thinking about the care you received in hospital after the birth of your baby, were you treated with kindness and About the same 8.2 understanding? Thinking about your stay in hospital, if your partner or someone else close to you was involved in your care, About the same 8.3 were they able to stay with you as much as you wanted? Thinking about your stay in hospital, how clean was the About the same 8.2 hospital room or ward you were in?

(Source: CQC Survey of Women’s Experiences of Maternity Services 2017)

During our inspection, we observed both community and ward staff speaking to patients and their families with compassion and understanding. The patients and relatives we spoke with were all positive about the care they had received. Women reported they had good support during labour, and were kept informed. One family made the comment that they were, “very happy with care, everyone has been amazing”. We observed a caesarean section in theatre; a screen was not used so the parents could see what was happening. Following delivery, the baby was placed onto the mother’s chest, and cord clamping delayed to allow the father to take a photograph. We also observed skin-to-skin contact given in theatre.

We did find that not all women in in-patient areas were aware of who their named midwife was.

We found that privacy and dignity for patients was maintained. On the labour ward, doors were closed and privacy curtains were in use.

Doctors told us they felt women attending the antenatal clinic were getting a poor experience, as there was not time to fulfil their expectations. However, we spoke with women in the antenatal clinic and no concerns were raised.

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Emotional support Care pathways were in place for baby loss at less than and over 20 weeks of pregnancy, the chaplaincy service could also provide support in these situations. There was a bereavement midwife who reviewed all women with fetal loss. An information file was also provided for staff to follow. ‘Remember my baby’ pictures were provided free of charge and memory boxes were in place.

The bereavement facilities were placed in between the birth centre and labour ward, which meant bereaved women might be able to hear women labouring, and their babies. Some midwives also commented that whilst women experiencing baby loss were given excellent care, it was a challenge if they were caring for another mother at the same time

There was a clinic to support women who had suffered baby loss, and women could transfer to a local hospice if they required more time with their baby.

Families were encouraged to be involved in the care of vulnerable patients, such as those with learning disabilities and teenage pregnancies. A number of specialist midwives were in post that could also provide additional support. Women and their families were invited to attend a meeting to discuss their care if any concerns were identified.

Understanding and involvement of patients and those close to them The women we spoke with felt they had been involved in decision-making and had been able to express their preferences. The women we spoke with said any questions they had posed had been answered, and they felt able to make informed choices about their care. On the postnatal ward, we saw information displayed in the kitchen advising women of timings for medication rounds, and meal times and visiting arrangements. On the labour ward there was a communication folder for patients. This included lots of information relating to the ward, and guidance, such as how to reduce the risk of infections. We saw a wide variety of information leaflets for women on topics such as fetal movements, and use of alcohol in pregnancy. The service recognised that obtaining feedback from women in the community was a challenge, and were looking at different options to increase friends and family test feedback rates. Is the service responsive? Service delivery to meet the needs of local people Bed Occupancy

From April 2016 to September 2017 the bed occupancy levels for maternity were generally notably lower than the England averages, with the trust’s occupancy rate being between 35-45% lower for every quarter.

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

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(Source: NHS England)

Women had the option to deliver at home, in the birth centre, or on the labour ward. Community midwifery teams demonstrated a good working knowledge of the socio-demographic profile of their caseloads. The community midwives were working with colleagues from neighbouring trusts to ensure women received appropriate care, at the right time and place.

Transitional care baby support workers had been employed and trained to work with babies, parents and staff; including, paediatricians during transitional care. They helped to ensure babies could be cared for on the ward and help avoid, where possible, admission to the neonatal unit. Staff told us there had been significant positive outcomes following implementation of this role.

To identify any gaps in service or knowledge concerning vulnerable women, the service had visited other trusts to observe their practice.

Meeting people’s individual needs There was a range of specialist midwives available to support women throughout their pregnancy, for example, those specialising in substance misuse and teenage pregnancies. There was also access to other medical specialities. The service had recently established a perinatal mental health service, with the support of community psychiatric nurses and medical staff. The maternity services provided care for women in vulnerable situations. Staff were experienced in identifying concerns, and would speak to women alone if they had concerns about domestic violence.

Information was easily available on the trust intranet on how to access interpreters, both in and out of hours. There were contact numbers for different interpreters, including basic sign language, as well as details on language line. We received mixed feedback in relation to interpreting services. Some staff gave examples of positive experiences when having to discuss sensitive issues, such as female genital mutilation (FGM); and they told us they tried to use same interpreters for continuity. However, other staff informed us that inappropriate interpreters had been sent; for example, those of the wrong dialect, or male interpreters sent for intimate female

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We were provided with a copy of the Yorkshire and Humber stillbirth and neonatal death charity (SANDS) audit tool from November 2017. Six of the questions related to interpreters and the audit identified possible gaps in service delivery. We were not provided with any information to indicate these gaps had been investigated.

The service had several staff who spoke other languages, and who could support general communication on a day-to-day basis.

There were specific service user groups to engage with the diverse local population to encourage them to seek early help and advice during pregnancy. For example the South Asian population and teenage mother who were smokers. The trust was also working with voluntary organisations to improve links with local communities to engage them in care planning and delivery.

Patients with a learning difficulty were provided with one to one support from the patient education team, with a comprehensive plan of care in place.

The transitional care unit allowed mother’s to stay with their baby when additional support was needed. For some women, this meant they did not have to be separated from their baby; for example, cases where baby would have otherwise been transferred to the special care baby unit.

The service felt they managed high risk women well, and that this group were still able to have choices over where to give birth. There was a birth choices clinic with a consultant midwife for women who want a particular birth that may not follow best guidelines. We were given an example of a woman who had a diagnosed breech, but chose to deliver in the birth centre. This was achieved by having senior midwifery available and medical care on standby.

The rooms on the delivery suite were large and had en-suite facilities and one allowed high dependency care to be delivered. There was a birthing pool available on the labour ward and in the birth centre. We observed community staff undertaking examinations in the woman’s room of choice.

Women who had miscarried were always provided with a single room. There were no follow up facilities for baby loss outside of the unit; women attended the gynaecology clinic, which was co- located with the antenatal clinic.

We spoke with women and observed practice and found care was patient centred. Women felt listened to and participated in care decisions. Access and flow The service consistently achieved better than the regional target of 90% for antenatal booking appointments at gestation less than 13 weeks. From January 2017 to December 2017, the figures were above 97%. There was a process in place to ensure women who did not attend appointments were followed up within the team, and by the individual caseload midwife.

We received a number of concerns from medical staff that the time allocated in clinic for the number of patients was not sufficient. We were told these concerns had been escalated, but no one was aware of any action in response to this. Ten-minute slots were allocated to see a patient; however, additional time was needed to input information to the electronic record. Feedback was received that the changes in records had not been accounted for in clinic slots. We spoke with two women in clinic who said they had experienced a short wait, but were happy with this. Medical staff also reported patients were sometimes brought back to clinic, as there was not enough time to make decisions about care. Incident data provided by the trust from July 2017 to January 2018 showed 23 incidents were reported by the antenatal clinic/day unit. Details

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At the time of inspection, the maternity assessment centre (MAC) could be accessed 12 hours a day and was midwife led. Women could be referred by their GP, midwife, or could self-refer for a variety of problems; such as, reduced fetal movements, or abdominal pain in pregnancy. The midwives in the MAC told us they often did not close at 10pm as women were still there. There were plans with the staffing uplift to provide a 24 hour service.

The MAC would divert patients to the labour ward or the birth centre if at capacity. Consideration had been given to expanding and reconfiguring the ambulatory care area, as it was a little cramped. The antenatal day unit closed at 5pm, this could impact MAC, as any women still in the department at 5pm would be transferred to the MAC. For example, the day prior to our visit there had been three women transferred.

During the inspection we observed the Snowdrop room in use when needed for another woman, staff reported at times this was an issue. However, a single room would always be made available. We were also told if a woman was in a smaller room on the labour ward and went on to require an instrumental delivery, they would have to be moved to a larger room to accommodate this.

The unit had closed twice between January 2017 and December 2017.

The midwives were available, on call, 24 hours a day for home births, as needed. Community midwives were directly notified of discharges from the electronic records system. Staff routinely searched for the previous days discharges and allocated patients depending on the capacity of each member on duty, and the caseload of the community midwife.

On a weekend, the all community midwives met at St Luke’s hospital and reviewed the discharges together to ensure all calls were shared equitably.

Staffing and flow was coordinated locally by the ‘hot desk’ midwife. Each morning they updated the matron, who attended the trust bed meetings. We observed beds being closed; for example, in the birth centre and ward M4, when staffing was reduced or acuity was high.

Learning from complaints and concerns Summary of complaints

From October 2016 to September 2017 there were 13 complaints about maternity care. The trust took an average of 71 working days to investigate and close complaints; this is not in line with their complaints policy, which states complaints should be resolved within 30 days of receipt. All the complaints were recorded as relating to ‘aspects of clinical treatment’.

(Source: Routine Provider Information Request (RPIR) P61 Complaints)

Updated information from the trust indicated that, as of January 2018, there were 29 formal complaints about the service.

There was a trust complaints policy and procedure in place, which staff were aware of. Staff said they would always try to resolve complaints when they arose, and would inform the shift leader/co- coordinator. Staff on wards M3 and M4 reported that complaints were generally about the environment, and work was ongoing at the time of inspection to improve this.

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Staff were unable to confirm if improvements in clinical care and treatment had been made following a complaint. From the ward meeting minutes we reviewed, complaints were not a standing agenda item. Complaints were reported and monitored at the divisional Clinical Governance Committee. A departmental action plan in relation to complaints management was provided, and this indicated actions were in place to strengthen processes around complaint management to enable a more timely response.

Is the service well-led?

Leadership Inpatient, outpatient, and community obstetrics were part of the women’s and children’s services division. The management structure in place had clear lines of responsibility and accountability. A triumvirate of divisional clinical directors, a divisional general manager and a divisional head of midwifery led the division. The service had three matrons in post, who divided responsibility for wards and departments led by ward managers. It was noted that several of the matrons and ward managers were in seconded posts. To support the staff and the acuity on the labour ward, two band 7 coordinators were on duty each shift. Daily safety huddles with representatives from each area enabled a service wide understanding of the staffing and activity each day. This allowed a clear multidisciplinary approach to assessing and managing any challenges. There was a board champion for maternity services. Discussions with the senior management team demonstrated a team that was patient focused, and who were committed to improving services. We received mixed feedback from staff about the visibility of the senior management team; however, most staff reported that changes in leadership meant a more proactive approach was being taken with issues within the service.

At ward level, staff were positive about their managers, saying they were supportive and approachable. All staff said they would feel confident escalating any concerns either to the ward lead or, in their absence, the ‘hot desk’ midwife.

Staff were encouraged to undertake professional development; this was evident in the number of staff in seconded roles. Other examples included recruitment for a deputy manager role and staff being supported to take charge of a shift. Vision and strategy The trust’s ‘Clinical Service Strategy 2017 to 2022’ identified a vision to be “an outstanding provider of healthcare, research and education, and a great place to work.” The trusts values had been revised to reflect the trust mission. These were, “we care, we value people and we are one team striving for excellence”. All staff were focused on delivering high quality and safe patient care. Senior staff had a clear direction for maternity services; and key areas of development and focus were identified. The maternity service improvement care plan was central to this, along with national care bundles and patient safety collaboratives. Alongside this were workforce plans, such as, developing the obstetric theatre team, and recruiting to allow a 24-hour MAC. The future for ambulatory care was also being discussed, with a view to improving patient flow and experience. The community midwifery managers had a vision for the service, which was developed and communicated with staff. This included continuity of care, increased engagement with women, and increasing the number of homebirths in Bradford.

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Culture We observed good teamwork between midwives and medical staff; and despite pressures, staff were motivated and positive about the work they did and the support provided to women. Community midwifery teams were open and supportive of each other. We observed senior doctors supporting junior staff. Staff felt supported by their line managers and encouraged to develop their skills. Staff felt able to escalate concerns and reported an ‘open door’ policy with regards to accessing managers. However, we did hear from a number of midwives that there was an acceptance around some areas of care and safety when impacted by reduced staffing numbers; and we noted this in some of our direct observations. For example, staff reported they would often not complete an incident form if one-to-one care during labour was not provided, or if an induction of labour was delayed because of staffing levels. We asked staff more about this, and they said it happened so frequently they were no longer reporting this as an incident. Some senior midwives spoke about a culture of midwives not taking ownership in terms of their professional development with regards to mandatory training. In the MAC, we saw a valuing people award, which displayed a certificate of recognition for a staff member. Governance Divisional quality and safety core group, clinical incident panel and mortality meetings took place each month. Risks, incidents, complaints, and lessons learned were discussed. All actions associated with serious incidents and complaints were managed via a maternity action tracker, which was monitored through the monthly core group meeting. This identified responsible individuals and defined actions. Assurance had to be gained before any areas could be marked as complete. We reviewed this document, which had 58 items on it. Thirty of these items were completed with assurance, or on track. Nineteen items were due review. Included in this was assurance about antenatal screening samples, and management of labour. There was evidence of ongoing review and actions taken. The information was disseminated to staff via two monthly forums, team meetings, and safety huddles. However, as previously identified, team meetings had not been occurring regularly and attendance was poor. We did not observe safety huddles being used effectively as a means of sharing information during our inspection. On the post-natal and antenatal wards staff said they often did not take place due to staffing pressures. This ‘block’ in the governance system was evident in the lack of learning staff were able to articulate in response to incidents Management of risk, issues and performance There was a women’s services risk management strategy in place, and this was currently under review to incorporate the new professional midwifery advocate role. The strategy outlined the processes for managing and escalating risks, as well as individual responsibilities. We reviewed the risk register, which had six risks identified. These risks related to mandatory and CTG training compliance, staffing, the external windows, and equipment for acute urological equipment in obstetric theatres. We were concerned that security within the department was not on the risk register and that immediate action was only taken when the inspection team raised concerns. We also felt that the management of patient records was a risk due to the multiple formats used. Whilst records were reviewed as part of other investigations, there was not a routine records audit in place. Most of the medical staff we spoke with raised concerns over the antenatal clinic. Many felt the framework needed revising to take the electronic patient record into account, and the complexity of

20171116 900885 Post-inspection Evidence appendix template v3 Page 191 many women who attended. We were told a review of this had been undertaken, but the trust was unable to provide evidence of this to the inspection team. Whilst we were told risk processes had improved and the weekly case reviews were well received by staff, many were unable to attend due to staffing pressures. Community midwives had lone worker devices, however, they described them as not user friendly, complicated to use, and did not maintain their charge. Staff ensured if there were any concerns, that they would undertake visits in pairs. Additionally, all home visits were to be completed by 3pm. Community midwives met at the hospital prior to homebirths. This meant they could collect the home birth equipment and arrive at the house together. As part of the preceptorship programme, newly qualified Band five midwives might be placed into the community during their first rotation. Community midwifery leaders had put a support package in place for these staff, which included a hints and tips manual, and they undertook observations of staff in community antenatal clinics. This meant staff were provided with support to consolidate their newly acquired skills. Where community midwives were called into support the hospital as part of escalation plans, they would be placed in low risk areas of work, such as the birth centre and antenatal and postnatal wards. Community staff also rotated into the birth centre to update their clinical skills. The service had a maternity dashboard, which reported performance data and showed comparisons with regional averages. This enabled the service to monitor outcomes and performance. A number of audits were undertaken; however, we lacked assurance over the pace of implementing changes as a result of these. For example, a MEWS audit was undertaken in March/April 2017. This was not presented to the quality committee until January 2018, with actions to be determined at another meeting in February 2018. There was no regular auditing of MEWS in place, so we were unsure how the trust was assured about this. Birth rate plus audit was completed in May 2017, but the recommendations were not outlined to the senior management team until December 2017. The additional resource for the specialist midwife roles was scheduled for discussion at the March 2018 meeting. We found significant issues concerning midwifery staffing and it had been on the departmental risk register since October 2015. Information management Community midwives had an agile working policy, which ensured they could access electronic antenatal notes in GP practices and on laptops. However, connectivity in the local area was not always possible. Staff could access information relating to polices and guidance electronically, and the system was easy to navigate. Staff received training on information governance and were aware of the importance of managing confidential patient information. We observed a comprehensive information board on the labour ward, with the names of consultants and doctors on call, which was regularly updated. We found a range of patient information leaflets available in the MAC; however, several were beyond their review date. For example, ‘nausea and vomiting’ had a review date of 2015, and ‘what should you do when your waters break and you are not in labour’ had a review date of 2011. Engagement There had been significant programme of work around staff engagement; focused on the tag line ‘let’s talk’. The programme included various ways of engaging with staff, including a monthly newsletter and informal group meetings with the chief executive. Alongside this, the appraisal

20171116 900885 Post-inspection Evidence appendix template v3 Page 192 process had been renamed ‘time to talk’; and staff felt this had changed the emphasis of the appraisal process to make it more meaningful. There were also annual staff awards, which had seen a significant increase in the numbers of staff and teams being nominated. The new pathways in development for vulnerable women plans to seek feedback from the women included. There are also plans to link with advocacy services to support those with a learning disability to participate and provide feedback on the pathways. We found there to be good links with the voluntary sector, to enable signposting to the most appropriate service. There were plans to have a service user engagement event, looking at specific groups who are not engaging as actively with services. The service liaised with chaplaincy services who advised looking at what the barriers are, before deciding on actions. We found evidence of public engagement in learning. For example, in the bereavement training women and grandmothers volunteered to provide insight for staff in specific religious beliefs and practices. An information leaflet was developed on third degree tears in conjunction with a woman who had experienced this. Learning, continuous improvement and innovation Specialist midwives reported good support from the trust with the pathway development work for vulnerable women. They hoped to expand the programme to develop a FGM clinic, which would also focus on education and prevention. The trust had maintained a supervision of midwifery team. Four staff had undergone the bridging programme to gain the Professional Midwifery Advocate (PMA) role. This new model of supervision was supported by NHS England and Health Education England. Four more staff were due to complete this training in February 2018, with a view to having formal session running by March 2018.

Following a cluster of serious incidents, the trust had invited the Royal College of Obstetricians and Gynaecologists to undertake a review of their maternity services. A number of recommendations came from this. A maternity service improvement plan had been developed to address the recommendations.

In recognition of the outcomes of the Maternal, New born and Infant Clinical Outcome Review Programme (MBRRACE) in relation to perinatal mortality, a number of actions had been taken. The stillbirth compliance care bundle had been implemented and the trust was in the first wave of the maternity and neonatal health and safety collaborative.

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