Frimley Park Hospital

Frimley Park Hospital provides acute services to a population of 400,000 people across north-east Hampshire, west Surrey and east Berkshire. It serves a wider population for some specialist care including emergency vascular and heart attacks. In addition to the main site, it runs outpatient and diagnostic services from Aldershot, Farnham, Fleet and Bracknell.

Frimley Park Hospital has around 3,700 whole time equivalent members of staff and hosts a Ministry of Defence Hospital Unit with military medical, surgical and nursing workforce fully integrated into the NHS staff.

We carried out this follow-up inspection in addition to our comprehensive inspection in November 2013, as Frimley Park Hospital was inspected during a pilot period when shadow ratings were not published. In order to publish a rating, we needed to update our evidence and inspect all core services.  Because we had inspected the trust so recently (in November 2013) we did not repeat some parts of our usual inspection process.  This included the unannounced visit (which took place at night) and the public listening event.  At the public listening event in November we heard directly from about 100 people about their experiences of care. 

In addition, due to the proximity of the junior doctor changeover date (the significant majority of the junior doctors changed post a day before the inspection) we did not speak with many of them during this inspection.  However the feedback from those spoken with during the November inspection was overwhelmingly positive, describing a high level of support from their consultants and registrars which they told us had had a resultant impact on their personal confidence levels and medical practice.  They went on to describe why this led to medical staff frequently returning to Frimley Park at a later stage of their training or as consultants.  Specific comments included one doctor stating that the level of support she had received in her day-to-day work was “outstanding”, and another that although the workload was sometimes very heavy, the senior staff “led by example” and were very approachable.  These findings are corroborated by the fact that Frimley Park is rated top for training within the Kent, Surrey and Sussex deanery by foundation trainees.

Overall, this hospital was rated as outstanding. We rated it good for providing safe and effective care and outstanding for being caring, responsive to patients’ needs and being well-led.

We rated A&E, medicine, surgery, critical care and end of life care as outstanding. We rated children and young people’s services, maternity and outpatients as good.

Our key findings were as follows:

Safe:

• Frimley Park Hospital was one of the first 12 trusts nationally to sign up to the NHS England “Sign up for Safety” Campaign. A safety culture was a priority for staff at all levels and was embedded throughout the trust. Learning from events was encouraged and we were given multiple examples throughout the services of how care had been improved as a result of incident reports and investigations.
• Wards were well staffed from both a medical and nursing point of view. Where shortfalls had been identified, the senior team were aware and action plans were in place to address this. Where temporary staff were employed there was sufficient training to orientate them to the trust.
• The hospital was clean and staff were witnessed to follow good hygiene practices. Audits were undertaken routinely by the trust and action was taken if areas or staff groups were not compliant with expected cleanliness standards.

Effective:

• Staff based care delivered on best practice guidelines. Local outcomes were regularly audited and the trust was able to demonstrate how it had changed practice to improve results for patient’s year on year. The trust also benchmarked itself, and compared well against, national comparators.
• There was strong multidisciplinary team working throughout the trust. Staff worked alongside each other for the benefit of patients receiving care. There were multiple Clinical Nurse Specialists who supported teams and patients in specific areas, bringing their own expertise and knowledge to develop innovative ways of improving services.
• The trust was committed to developing seven-day services throughout. Good progress had been made towards this, and plans demonstrated that where this had not been completely rolled out, business cases had been accepted by the board and recruitment was ongoing.

Caring:

• Treating patients with dignity and respect, as well as valuing them as individuals, was evident throughout the organisation and found to be a fundamental part of the culture at Frimley Park Hospital.
• Throughout our inspection patients and their relatives told us how caring staff had been towards them, and how staff had ‘gone the extra mile’ to support them during their admission to hospital. We also witnessed exemplary care being given on many wards.
• Gaining feedback from patients and their relatives was a priority and was used by the trust to improve the care that was delivered. The trust was above the national average in the national Friends and Family test, both in terms of those recommending the hospital to others and in the response rate.

Responsive:

• We saw multiple examples of how services had changed the way they delivered care – either through feedback or by working with the local community to develop the service.
• In areas where there were problems with the flow of patients, there was evidence of inter and intra departmental working to try and improve patient pathways. We witnessed many innovative solutions and saw examples where they had learned from other trusts that had experienced similar difficulties.
• The trust had worked hard to embrace patients who were more vulnerable or had increased needs. There was good support for patients living with dementia or a learning difficulty, and the trust had worked with the local Nepalese community to improve methods of communication.

Well-led:

• Staff engagement at the trust was impressive. The CEO led from the top with a clear mantra that staff worked ‘for Frimley’ not ‘at Frimley’ and the concept of the ‘Frimley Family’ was felt throughout the inspection. Staff were encouraged to, and rewarded for, improving patient experience and therefore at all levels staff reported feeling empowered to develop their own solutions to enhance their services. There was a strong sense of support and alignment between clinicians and managers, both of whom reported working together to achieve their aim of providing outstanding patient care.
• There was a clear vision and values that had been developed with staff to ensure that they aligned with a service they wanted to work for. As a result “committed to excellence; working together; facing the future” was embedded throughout the trust and underpinned fundamental behaviours. The potential acquisition of another provider had been well communicated with staff and at all levels there was confidence that the service provided at Frimley Park Hospital would remain at the current high standard.
• The trust demonstrated a strong patient-centred culture, which considered that public engagement was essential in developing services. The evident strength and depth of leadership at both board and ward level was outstanding, the benefits of which were clearly demonstrated by the consistency of high quality care provided across the domains and throughout the core services and should be congratulated.

In addition to the above, we saw multiple specific areas of good and outstanding practice:

• The A&E department had been redesigned by taking patients’ views into account, and provided an environment that helped to deliver exceptional patient care (including specific dementia-friendly areas).
• The four-hour target was consistently met, and the other core services that worked with the A&E department acknowledged that the target was everyone’s responsibility.
• Joint working between the elderly care physicians and the A&E department led to improved patient experience and reduced unnecessary admissions.
• ‘Round table’ discussions were used as a learning tool, and there were well-developed Mortality and Morbidity (M&M) meetings, which included dissemination to all levels of staff.
• There was a drive to increase incident reporting by all staff groups, especially medical staff (i.e. doctors).
• The management of medical outliers, including the method of communicating with teams, ensured ownership and daily (early) review. 
• Specialist advice was available for GPs and the A&E department and rapid access clinics reduced unnecessary admissions.
• Theatre utilisation had improved, and resulted in a cancellation rate of 0.6% between October 2013 and June 2014.
• There were communal dining areas on the orthopaedic wards.
• There was a high standard of care provided for patients at the end of their life, and we saw that staff went to great lengths to respect and accommodate the wishes of patients and their families, including the use of the ‘Time Garden’.
• The trust used and audited the trust wide ‘Personalised Care Plans for the Dying Patient’ in place of the previously used Liverpool Care Pathway.
• The A&E department used memorial boxes for recently bereaved relatives and contacted them six weeks following the death of a relative.
• The ophthalmology service had received a ‘Clinical Service of the Year’ award from the Macular Society
• Joint working with specialist providers allowed patients to attend outpatient clinics closer to their home rather than having to travel to another provider further away.

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

The trust should:

• Review nursing staffing levels and skill mix in paediatrics (services for children).
• Ensure paediatric staff have the necessary skills to identify and manage the deteriorating child.
• Review how training data is recorded within paediatrics, to ensure that records are accurate.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Frimley Park Hospital NHS Foundation Trust is a single site trust with 725 beds serving more than 400,000 patients across north-east Hampshire, west Surrey and east Berkshire. However, its catchment for some services (such as emergency vascular and heart attacks) is much wider. In addition to the main hospital site at Frimley, the trust runs outpatient and diagnostic services in Aldershot, Farnham, Fleet and Bracknell, bringing a range of services closer to these communities.

Frimley Park Hospital also incorporates a Ministry of Defence Hospital Unit, with fully integrated military medics contributing to patient services.

Since achieving foundation trust status in April 2005, Frimley Park Hospital has been able to invest in a range of services, including a modern eye unit and a new emergency department that contains one of the biggest resuscitation units in the country. It has also opened its dedicated cardiology wing – this has an accredited regional heart attack centre that provides primary angioplasty 24 hours a day, seven days a week. There have also been significant investments in older people’s care and end-of-life care.

Our inspection team spent two days visiting the hospital, and we conducted a further unannounced visit one week later. This included a night visit. We held a public listening event in Frimley Park and heard directly from about 100 people about their experiences of care. We spoke with more than 80 patients and over 100 staff during the inspection.

Our analysis of data from our ‘Intelligent Monitoring’ system before the visit indicated that the hospital was operating safely and effectively across all key services. The trust’s mortality rates were as expected or better than expected across all key areas. When we inspected, we found that services were of a good standard at all times of day, including at night.

However, we had some concerns about the coordination and experience of care for people living with dementia. This included staff training and the documentation of people’s needs. We looked closely at this when we visited at night, and found staff to be very caring and compassionate. However, we saw that they lacked training to underpin their skills. We also noted that staff were not consistently using the ‘Blue Butterfly’ system to identify people with dementia.

We were particularly impressed by the leadership of the trust. This has been stable and consistent for a number of years and still remains dynamic and clear in its strategy for improvement. The executive team’s passion for excellence was clear, and this created a workforce of dedicated staff caring for people at Frimley Hospital.

Staff were overwhelmingly happy working at the trust, and we met many people who had returned to work at Frimley because of the experience they had had there previously. This was particularly evident among the consultant doctors, many of whom had been junior doctors or trainees at the trust earlier in their career.