Barnsley Hospital

Barnsley NHS Foundation Trust provides a range of acute hospital health services at Barnsley Hospital. The trust serves the Barnsley area which has an estimated population of 236,000. In total the trust had 359 beds. Barnsley is in the 20% most deprived areas in the country.

We inspected Barnsley NHS Foundation Trust as part of our comprehensive inspection programme. We carried out an announced inspection of hospital between 14 -17 and July 2015. In addition, an unannounced inspection was carried out on 26 July 2015. The purpose of the unannounced inspection was to look at the Emergency department and medical wards at the weekend.

Overall, we rated this trust as requires improvement and we noted some outstanding practice and innovation.

However, improvements were needed to ensure that services were safe and well-led.

Our key findings were as follows:

• Staffing levels were planned and monitored. There were some shortages; most notably there was a shortage of children’s nurses at the trust.
• There had been no cases of hospital acquired MRSA since 2008. The rate of hospital acquired C.difficile was within the trust’s trajectory.
• The adjusted mortality rates had reduced significantly in the trust over the past year. Analysis across a range of indicators showed there was no evidence of risk regarding mortality.
• The trust performed mostly above the 95% standard for percentage of patients waiting to be seen within four hours since May 2014, with the exception of December 2014 and May 2015.
• Assessments of patient’s nutritional needs were recorded. Across the trust, we found patients were supported to eat and drink.
• Following transfer to a new IT appointment system, the trust had discovered a backlog of outpatients who potentially needed a follow-up appointment. Work was underway to clinically validate the list and ensure all relevant patients were offered a review appointment by 31 January 2016.
• Leadership at the trust had been subject to significant change over the last 20 months. Staff spoke positively about the trust leadership.

We saw several areas of outstanding practice including:

• The uro-gynaecology nurse specialist had introduced “percutaneous tibial nerve stimulation for overactive bladders” following a successful business case to the trust. This improved symptoms for patients and made cost savings for the trust. Audit data from 2014 demonstrated improved outcomes for women.
• The dermatology service described a tele-dermatology project they were providing in conjunction with the local Clinical Commissioning Group whereby some GP practices could send in pictures of patient problems and receive an electronic treatment plan within three days. The service had also recently been approved to provide private cosmetic procedures (such as Botox) and was seeking to use these as a revenue generator for the trust.
• We saw that staff in the breast clinic had developed a simple tool for patients to remind them to take their medication. The staff had developed a card, covered in a picture of brightly coloured tablets that could be hung from a door handle at their home such as a kitchen cupboard. This had been shared at an internal nursing conference and staff in other areas of the trust were using for their patients.
• A midwife had won the prestigious 2015 Royal College of Midwifery’s (RCM) Philips AVENT National Award for Innovation in Midwifery. They created a secure staff social networking site called ‘Ward-book’ which was used by midwifery staff at the hospital to communicate important messages across the department. Each week the Head of Midwifery wrote a departmental update which gave staff the opportunity to feedback in real-time and this was posted on the system. The Ward-book was used as a virtual notice board. It helped communication between managers and staff and helped improve the outcomes for patient care.
• Pharmacy robots had been introduced at the trust in July 2014. This has reduced errors and increased staff capacity.

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

Importantly, the trust must:

• ensure all patients attending the emergency department, have an initial assessment undertaken by a suitably qualified healthcare professional in accordance with national guidance.
• ensure that children attending the hospital are cared for by nursing staff who have the qualifications, competence, skill and experience to do so safely.
• ensure oxygen is prescribed in line with national guidance.
• ensure that medicines reconciliation is completed in 24hrs and meets local and NICE guidance.
• ensure compliance with the five steps for safer surgery.
• ensure suitable patients are offered laparoscopic colorectal surgery in accordance with NICE guidance.
• address the backlog of outpatient follow-ups.

In addition the trust should:

• review processes to enable staff to receive mandatory training on a regular basis.
• confirm guidance to staff, based on best practice, as to the recording of verbal consent by patients in the clinical record.
• review sign language interpretation availability for patients whose main or only means of communication is British Sign Language (BSL).
• monitor the consistent use of the sepsis screening tool and timely completion of the interventions on the sepsis pathway.
• review the out of hours medical staffing provision within medicine.
• work with local services to reduce the number of medical outliers and medically fit patients in hospital to improve patient flow and reduce bed occupancy.
• work with medical consultants to implement a robust system of timely mortality review.
• work with ward staff to improve the understanding of the specific requirements associate with Duty of Candour.
• undertake regular infection prevention and control ward audits.
• improve the quality of medical record keeping and include this in the audit programme.
• monitor and reduce the number of out of hours bed moves.
• undertake a review of historic serious incidents and recommendations made to ensure learning is carried forward in to current areas of clinical practice
• provide appropriate access to IT systems for appropriate staff, including temporary staff.
• ensure medicines are stored at the correct temperature.
• review medical note taking including prescription documentation.
• review infection prevention and control practices within surgical areas including clinical stock rotation, environmental cleanliness and the changing rooms within main theatres environment
• ensure there are sufficient numbers of staff with suitable qualifications, competence, skill and experience to provide care to patients within trauma and orthopaedics.
• continue to take action to ensure the urology service meets patient need.
• improve compliance with national emergency laparotomy audit.
• undertake a full assessment of the area currently used for lucentis and its environmental and engineering suitability for service provision in the current facility.
• consider the amount of sessions for ward rounds for surgeons.
• consider undertaking a review of waiting facilities within theatre reception area.

• store records in line with data protection requirements.
• meet the government targets for antenatal screening between 10 and 12 weeks gestation relating to foetal abnormality.

• consider monitoring of waiting times in the CAU.
• support incident reporting and ensure timely response to investigations and clear lines of communication to staff in order that lessons are learnt in a transparent manner.
• consider improving the environment in the POPD waiting area.
• review the safe storage of patient records in the children’s outpatients department.

• take action so advanced care planning and preferred place of care are considered by the MDT in a timely way in order that patients wishes at end of life can be met.

• quality assure radiology reports generated by voice recognition.
• take action to improve cancellation and DNA rates.
• take action regarding the visibility of patient information on their electronic check in screens.
• review the seating arrangements in the phlebotomy department and main outpatients’ areas to provide seating for patients with differing needs.
• review the facilities and waiting areas for inpatients to improve the maintenance of privacy and dignity.
• review processes for reporting of x-ray films and CT scans to ensure acceptable and consistent reporting times are achieved.
• include the quality of record keeping in medical records and the use of WHO checklists in its audit programme.

Professor Sir Mike Richards

Chief Inspector of Hospitals