Weston Area Health NHS Trust Weston General Hospital Quality Report Weston General Hospital Grange Road Uphill Weston-Super-Mare Somerset BS23 4TQ Tel:01934 636363 Date of inspection visit: 20-22 May 2015 Website:www.waht.nhs.uk Date of publication: 26/08/2015 This report describes our judgement of the quality of care at this hospital. It is based on a combination of what we found when we inspected, information from our ‘Intelligent Monitoring’ system, and information given to us from patients, the public and other organisations. Ratings Overall rating for this hospital Requires improvement ––– Urgent and emergency services Requires improvement ––– Medical care Inadequate ––– Surgery Requires improvement ––– Critical care Requires improvement ––– Maternity and gynaecology Good ––– Services for children and young people Good ––– End of life care Good ––– Outpatients and diagnostic imaging Good ––– 1 Weston General Hospital Quality Report 26/08/2015 Summary of findings Letter from the Chief Inspector of Hospitals Weston Area Health NHS Trust provides acute hospital services and specialist community children’s services to a population of around 212,000 people in North Somerset, with over 70% of people living in the four main towns of Weston, Clevedon, Portishead and Nailsea. A further 3.3 million day trippers and 375,000 staying visitors increase this base population each year. It has three locations that are registered with the Care Quality Commission. These are Weston General Hospital which has 265 beds, The Barn in Clevedon and Drove House which both provide special children’s services. At the time of our inspection the trust was subject to a transaction process, in which Taunton and Somerset NHS Foundation Trust was the preferred acquirer. This was at the Trust Development Authority’s Gateway 2. We inspected this trust as part of our in-depth hospital inspection programme. The trust was selected as it is an example of a moderate risk trust according to our new intelligent monitoring model. Our inspection was carried out in two parts: the announced visit, which took place on the 19-22 May 2015, and the unannounced visits, which took place on 30 May and 5 June 2015. We judged that the hospital overall required improvement. There were serious concerns with respect to safety within urgent and emergency care services and medical services. Throughout the hospital we saw staff providing care and treatment to patients in a caring and compassionate manner. The service for children and young people was outstanding overall and in particular with respect to the caring and responsive approach of staff. Our key findings were as follows: Safe: • Overall we rated the safety in the hospital as inadequate. There were serious concerns with respect to safety within urgent and emergency care services and medical services were also rated as inadequate. Safety within surgery services and critical care required improvement and in all other areas was rated as good. • Within the emergency department we found that at times when there were a higher number of people attending the emergency department, patients were not always assessed or prioritised in a timely manner. This meant they were not protected from the risk of avoidable harm. Whilst they were waiting in the corridor to be admitted to the department (for sometimes longer than an hour) patients were not adequately monitored by hospital staff, although ambulance staff were with them. There was no initial assessment on arrival to determine patients’ priority in relation to others waiting and those already in the department. Patients did not receive assessment in line with College of Emergency Medicine guidance. We observed that under normal conditions patients were assessed within College of Emergency Medicine guidance. • Self-presenting patients were not always assessed within 15 minutes in accordance with College of Emergency Medicine guidance. This meant that staff were not able to promptly identify or rule out serious or life-threatening conditions and prioritise patients accordingly. • We wrote to the provider to inform them of these concerns and required them to inform us of the action which they would be taking to rectify these issues. The response that we received showed that the trust had taken urgent action to deal with the risks identified. • Medical staffing within the hospital was a concern, particularly within medical services, surgical services and urgent and emergency care. There was a significant deficit in the number of consultants against the funded establishment, which resulted in unsustainable consultant rotas and reduced support for junior doctors. Junior doctors within medical and surgical services reported that they were undertaking tasks, unsupervised, for which they felt ill prepared or competent to perform. 2 Weston General Hospital Quality Report 26/08/2015 Summary of findings • In the area known as the high care unit on Harptree ward, there were insufficient numbers of appropriately qualified and skilled nurses deployed to care for high dependency patients. We raised this as a concern with the trust during our inspection and subsequently required, in writing, additional evidence to demonstrate what had been put in place to ensure that patients were not at the risk of harm. We received information which demonstrated that the trust had taken action to resolve the immediate concerns raised. • Although incident reporting was slightly above the England average, we found that feedback to staff about incidents reported often did not occur. This meant that staff, particularly medical staff, were not encouraged to report incidents. Some junior doctors reported they had been discouraged from reporting due to the negative response of some consultants. Reporting of incidents by junior doctors was low. The trust had identified that feedback on incidents was an area which required improvement and they were reviewing processes and updating the electronic reporting system to enable improvements. In some services, learning or improvements made as a result of incidents were not monitored or documented. • Nursing staffing was mostly safe in numeric terms, although there was a reliance on bank and agency staff to ensure that shifts were covered. • The trust had the lowest midwife to birth ratio in the country although midwives provided antenatal and postnatal support to approximately 1,500 women a year. All women were provided with one-to-one care when in labour. The supervisor of midwives to midwife ratio was above (worse than) the recommended level of 1:15. However, the trust had recruitment in place to improve this number. • The hospital was clean, despite some areas requiring refurbishment. Refurbishment of the theatre department was ongoing at the time of our inspection. Hand hygiene was seen to be good, with staff washing their hands, using alcohol gel as appropriate and observing the “bare below the elbows” policy. Most areas of the hospital had achieved the 95% compliance rate with infection control audits and those which had not were showing an improvement over time. Despite this, there had been a number of outbreaks of Norovirus in the hospital, which was attributed to a high prevalence within the community. There had been a higher number than expected cases of Clostridium difficile in the hospital in 2014-15, although this had reduced towards the end of the year and at the time of our inspection the trust had not had a case in 90 days. • There was a high incidence of pressure ulcers within the hospital, although the trend had decreased by 20% over the year prior to our inspection. The trust had been actively working to reduce the incidence of pressure ulcers. There were also improved rates of harm-free care within the hospital at the time of our inspection. • There were two never events in the hospital in the 12 months prior to our inspection. We identified a third never event took place in our review of information provided to us. This had not been reported as such. We asked the trust to look into this with the North Somerset Clinical Commissioning Group. • There were concerns regarding the audit of the use of the World Health Organisation surgical safety checklist. There was no policy or protocol regarding the carrying out of the audit. Within main theatres, the audit was not carried out adequately and there was not consistent improvement as a result of the audit. Despite this we observed good practice with adherence to the checklist protocol. There were concerns, however, regarding the debrief (which was not audited) where full attendance of staff was required but at the time of our inspection, this occurred only 78% of the time. • Staff were aware of their obligations under the new Duty of Candour regulation which, from November 2014, required organisations to inform and apologise to all relevant parties about specific patient safety incidents. We noted that this had not been applied in one instance where it should have been. • Safeguarding processes were clear throughout the hospital, including in services for children and young people. Training in safeguarding in most areas was below the compliance rate of 90% set by the trust. Staff training on the children’s ward was however, above the compliance rate. Effective • The hospital overall required improvement in the effectiveness of services. • There was a comprehensive programme of nursing audit in the hospital. 3 Weston General Hospital Quality Report 26/08/2015 Summary of findings • Although in most areas there was a programme of clinical audit, there was no evidence that actions had been followed-up, the details of learning identified or that this had been disseminated. Within medical services there was limited evidence that patient outcomes were measured or monitored or that care and treatment was provided in line with evidence-based guidance or best practice. • Within maternity and gynaecology services; children and young people’s services and end of life care, there was evidence that care was provided in line with best practice.