Bradford Royal Infirmary

Updated 26 May 2023

Pages 1 and 2 of this report relate to the hospital and the ratings of that location, from page 3 the ratings and information relate to maternity services based at Bradford Royal Infirmary.

We inspected the maternity service at Bradford Royal Infirmary as part of our national maternity inspection programme. The programme aims to give an up-to-date view of hospital maternity care across the country and help us understand what is working well to support learning and improvement at a local and national level.

We will publish a report of our overall findings when we have completed the national inspection programme.

We carried out an announced focused inspection of the maternity service, looking only at the safe and well-led key questions.

We did review the rating of the location and our rating of this hospital ​improved​.

We rated it as ​good​ because:

Our ratings of the Maternity service changed the ratings for the hospital overall. We rated safe as ​requires improvement​ and well-led as ​good​ and the hospital as ​good​.

How we carried out the inspection

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

Updated 9 April 2020

Our rating of this service improved. We rated it as good because:

• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it. Safeguarding training levels had improved since the previous inspection.
• The service provided mandatory training in key skills to all staff and made sure everyone completed it. Compliance with mandatory training had improved since our previous inspection.
• The service provided care and treatment based on national guidance and evidence-based practice. At the previous inspection we found that several policies and guidance had gone past their review date. At this inspection we checked six clinical guidelines and polices, and found they were all within their review date.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. Staff took time to interact with patients and those close to them in a respectful and considerate way.
• The service had a vision for what it wanted to achieve and a strategy to turn it into action, developed with all relevant stakeholders. The vision and strategy were focused on sustainability of services and aligned to local plans within the wider health economy. Leaders and staff understood and knew how to apply them and monitor progress.
• Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service promoted equality and diversity in daily work and provided opportunities for career development. The service had an open culture where patients, their families and staff could raise concerns without fear.
• People could access the service when they needed it and received the right care promptly. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were in line with national standards.
• Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients' consent. They knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health. They used measures that limit patients' liberty appropriately.
• Staff completed and updated risk assessments for each patient and removed or minimised risks. Staff identified and quickly acted upon patients at risk of deterioration. The trust had appointed a sepsis nurse in October 2018 who had rolled out a series of improvements. This included staff training, developing standard protocols and the establishment of a deteriorating patient group.

However:

• The service did not always have enough nursing staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Despite this we found the service monitored this well and had mitigation in place to manage staffing issues.
• Performance in national audits did not always demonstrate good outcomes for patients. The service had a higher than expected risk of readmission. From February 2018 to January 2019, patients at Bradford Royal Infirmary had a higher than expected risk of readmission for elective admissions and for non-elective admissions when compared to the England average.
• The service had a higher than expected risk of readmission. From February 2018 to January 2019, patients at Bradford Royal Infirmary had a higher than expected risk of readmission for elective admissions and for non-elective admissions when compared to the England average.
• The endoscopy unit had failed to achieve the Joint Advisory Group on Endoscopy (JAG) accreditation in March 2018. Staff explained this was due to concerns with patient flow and staff competencies. The service had appointed a new manager to implement an action plan to regain accreditation and staff told us that the unit was online to achieve this.

Updated 9 April 2020

Our rating of this service improved. We rated it as good because:

• We rated safe, effective, caring, responsive and well led as good.
• Nurse staffing levels had improved and an acuity and dependency tool was in use. Managers regularly reviewed and adjusted staffing levels and skill mix, and gave bank and agency staff a full induction.
• Compliance with safeguarding level 3 training had improved and targets were being met. Staff understood how to protect children, young people and their families from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it.
• The environment on the children’s wards had improved and now met individual’s needs. The design, maintenance and use of facilities, premises and equipment kept people safe. Staff were trained to use them. Staff managed clinical waste well.
• The service provided care and treatment based on national guidance and evidence-based practice. Staff monitored the effectiveness of care and treatment. They used the findings to make improvements and generally achieved good outcomes for children and young people.
• Staff treated children, young people and their families with kindness and compassion, they provided emotional support and involved children, young people and families in decisions about their care.
• The service was inclusive and took account of children, young people and their families' individual needs and preferences. Staff made reasonable adjustments to help children, young people and their families access services. They coordinated care with other services and providers.
• The service had improved the time taken to deal with complaints.
• Leaders had the skills and abilities to run the service. Staff felt respected supported and valued. All staff were committed to continually improving the services.

Updated 24 June 2016

We rated this service as good overall.

We found the relationships within the unit had improved. Senior managers now attended team meetings and were more visible on the wards. Governance structures were still not embedded and clinical leads had only recently come into post.

Staffing was adequate to meet patient needs and medical staff now worked one week in seven on ICU, in-line with national standards. Nursing staff had access to critical care training at the local university. Following the previous inspection we found that the service had reviewed the ward area and redesigned access to the sinks to improve infection control. The service planned to move the four HDU beds from a bay on a ward to a larger area which would allow patients to be cared for in a more suitable environment.

The capacity of the service to meet demand remained an issue. The bed occupancy for the unit was about 92% and patients were sometimes being cared for in recovery in the nucleus theatre because there was not a bed available on ICU. It was unclear if the new unit would be sufficient to reduce the occupancy rates because the number of ICU beds was not being increased. There had been no review of unmet demand for beds, which was identified as an action from the previous inspection and quality key indicators reports. The service was still not seeing all patients within 12 hours of admission although improvements had been made and processes put in place to mitigate the risk.

Patient outcomes information was not always completed and audits from patient outcomes were not always available. However the service did complete Intensive Care National Audit and Research Centre (ICNARC) data and it was used to benchmark against similar organisations. The service had not reviewed policies and procedures to ensure they adhered to professional standards and guidelines.

Delayed discharges of over four hours still occurred. However, the number of delayed discharges of over four hours had reduced since the last inspection and delayed discharges were better than similar units. Quicker discharges were facilitated by staff attending bed meetings to discuss discharges from ICU.

Updated 24 June 2016

We rated this service as good because people at the end of their life were cared for within the hospital by ward staff, who were supported by a hospital specialist palliative care team. This team worked closely to the national Gold Standards Framework to ensure that patients experienced a good quality of care at the end of their life. The team was supported by a consultant in palliative care medicine ensuring that appropriate and timely advice was available to staff across the wards and district. In addition, patients and their relatives had access to support through the ‘Gold Line’ a telephone service, available 24 hours a day, seven days a week.

Care was arranged to meet the needs of the individual and to ensure where possible that people were able to spend the end of their life in their preferred place of death. There were systems and arrangements in place to ensure that people’s diverse needs were respected and supported. There was collaborative working across multi-disciplinary teams and other agencies to ensure that patients with cultural, religious and special needs such as a learning disability were incorporated into their individual care packages.

Updated 26 May 2023

Updated 9 April 2020

Our rating of this service improved. We rated it as good because:

• The service provided mandatory training in key skills to all staff and made sure most completed it.
• Staff understood how to protect patients from abuse.
• The service had enough competent staff and they worked together as a team.
• Records were clear, up-to-date and stored securely.
• The service used systems and processes to safely prescribe, administer, record and store medicines.
• The service managed patient safety incidents well and monitored the effectiveness of care and treatment.
• Staff treated patients with compassion and kindness.
• Leaders had the skills and abilities to run the service.
• Staff felt respected, supported and valued.

However, we also found:

• The service did not always control infection risk well, although they kept the premises visibly clean.
• Outpatient services were not always available seven days a week.
• There were gaps in emergency equipment check records.
• There was no formal system in place to ensure security of prescription pads.

Updated 15 June 2018

Our overall rating of this service stayed the same. We rated it as good because:

• Patients were protected from abuse because staff had received training in safeguarding, there was a lead nurse for safeguarding and staff reported good support from the psychiatric liaison team.

• Staffing numbers were reviewed regularly to ensure they were safe despite significant challenges.
• Learning was evident in discussions with staff about incidents and staff knew how to report incidents.
• The trust had ensured relevant staff working in surgery complied with the five steps to safer surgery process and that the WHO surgical safety checklist was consistently followed and audited.
• Policies and pathways were based on guidance from the Royal College of Surgeons and the National Institute for Health and Care Excellence (NICE).
• Enhanced recovery pathways were in place, for example for patients undergoing elective joint replacement surgery.
• Staff worked together as a team for the benefit of patients. Doctors, nurses and other healthcare professionals supported each other to provide care.
• The trust had a multi-faith chaplaincy service and bereavement service and patients confirmed staff provided emotional support. The bereavement service scored positively in recent audits.
• All wards were dementia friendly and had a wide range of resources available for people living with and caring for people with a dementia. Specialist dementia nurses were employed by the trust and access to learning disability liaison support was available.
• The trust’s performance for elective and non-elective admissions relating to overall length of stay was better than the England average.
• The surgical division had a management structure in place with clear lines of responsibility and accountability; senior staff were motivated and enthusiastic about their roles and had clear direction with plans in relation to improving patient care.
• Staff told us the division had strong leadership and senior managers were visible and engaged with staff.

However:

• Although staff received mandatory training, compliance rates were variable; the rates of completion for Mental Capacity Act training and also for the completion of staff appraisals were below trust targets.
• Environmental issues were identified with floors in theatres although these were in the process of being addressed by the trust.
• The trust recognised there remained a risk of contamination of the clean scrub area during the movement of dirty instruments from theatre.
• The trust had higher than expected risks of readmission for both elective and non-elective admissions when compared to the England averages.
• The percentage of cancelled operations at the trust was higher than the England average.
• The trust had received a concern from the National Joint Registry Outlier Committee drawing attention to the mortality rate for knee replacements.
• The trust was not meeting its policy that complaints should be resolved within 30 days of receipt and took an average of 55 days to investigate and close.
• Patients described the care they received in positive terms and friends and family recommendation rates were over 90% but response rates were very low.

Updated 15 June 2018

A summary of our findings about this service appears in the overall summary.

Our overall rating of this service improved. We rated it as good because:

• Patients were clinically streamed on arrival in the department, with the oversight of qualified nurses and triaged promptly, usually with medical input.
• Staff acted promptly to escalate their concerns when a patient’s condition deteriorated, so that the patient received the most appropriate care and treatment.
• Patients consistently gave positive feedback about their experience in the emergency department. Staff provided appropriate and timely support to help patients cope emotionally with their care and treatment.
• Almost all patients were assessed with 15 minutes of arrival during our inspection, which mainly met our previous concerns that not all patients were being assessed promptly, and waiting times of patients between four and 12 hours showed a long term trend of improvement.
• An agreement with a neighbouring mental health trust provided support for patients experiencing ill mental health and we observed this multidisciplinary arrangement worked well although we did observe some delays for assessment.
• Medical and nursing staff, of all grades, were deployed in sufficient numbers to support a safe service, staff received regular appraisals and staff development opportunities were consistently well received by staff.
• The emergency department followed recognised evidence-based care and treatment guidelines and participated in national audits to enable its practice to be compared.
• The emergency department had implemented electronic patient records so that the records of patients were complete, accessible, audited and met our previous concerns as to patient confidentiality.
• Staff reported incidents and applied safeguarding procedures for adults and children appropriately; Staff had an appropriate understanding of consent, mental capacity, and deprivation of liberty safeguards.
• Risks were identified, regularly reviewed and mitigation and action was taken. the department’s processes and systems were reviewed through regular audit and monitored to support improvement.
• The new emergency department met our previous concerns about the limitations of the previous department’s facilities; the department worked closely in liaison with the acute assessment area, the medical admissions unit and the ambulatory care unit to support the efficient flow of patients.
• Leadership and governance of the emergency department was stable with elements of good practice and staff spoke positively about the clinical leadership of the department; medical and nursing staff at all levels were clear about their roles; the culture was positive, friendly and open with high staff morale.
• The vision and strategy for the emergency department was supported by the clinical services strategy for 2017 to 2022 and the department embraced the overall mission of the trust to provide the highest quality healthcare.
• Information was used to monitor and manage the operational performance of the department, and to measure improvement.

However:

• The layout of the reception area did not support the confidentiality of patients.
• Signposting to the emergency department in the hospital needed to be improved.
• Nurse practitioner recruitment needed to be completed so that the ambulatory care unit (ACU) was fully staffed for extended hours.
• Mandatory training needed to be fully completed by all staff, including staff training and competency assessments to support the safe use of patient group directions.
• Improvements were required for sepsis outcomes for the emergency department, the unplanned re-attendance rate within seven days and to the high number of patients leaving the department before being seen.
• Some key operational performance information (particularly compliance with the 95% standard) was not presented clearly in the emergency department.
• Information for patients was not available in the reception area and further information in printed form was not available for patients and their carers, particularly about the support available for patients with mental ill health, dementia or learning disability.
• The friends and family test for the emergency department had achieved a very low response rate particularly in the last 12 months.
• The trust’s policy commitment to resolve complaints within 30 days was not always being met, although recent improvements in complaint handling had been achieved.
• The links with primary care services needed to be developed further to support the emergency department’s role in health promotion and the use of joint patient pathways to avoid unnecessary referrals to the emergency department.