Hinchingbrooke Hospital

Updated 8 June 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 Hinchingbrooke hospital.

We inspected the maternity service at Hinchingbrooke Hospital 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.

Hinchingbrooke Hospital is in Huntingdon in Cambridgeshire and is part of the North West Anglia NHS Foundation Trust. The maternity division is configured over 2 sites and the current birth rate at Hinchingbrooke Hospital is 1925 births for year ending March 2023. The hospital serves a lower proportion of mothers in the 1st, 3rd & 4th deprived deciles at booking compared to the national average. A higher proportion of mothers were in the 2nd most deprived decile, 13% compared to 12% nationally.

Maternity services offered by the hospital included antenatal clinics, fetal medicine, complex antenatal care, a maternity triage service, acute intrapartum care, a midwifery led birthing unit and postnatal inpatient services. Women and pregnant people accessed their personal care records via a digital application.

Our rating for maternity is Good.

We did not review the overall rating of the location therefore our rating of this hospital ​stayed the same​

Hinchingbrooke Hospital overall rating is Requires improvement.

We also inspected one other maternity services run by North West Anglia NHS Foundation Trust. Our reports are here:

Peterborough Hospital – https://www.cqc.org.uk/location/RGN80

How we carried out the inspection

This maternity thematic review was a focused inspection; we inspected the domains of safe and well-led using the CQC’s specific key lines of enquiry designed to support the National Maternity Services Inspection Programme.

Inspectors visited maternity services on 5 April 2023. We spoke with 20 staff and reviewed 10 sets of patient care records. We looked at a wide range of documents including audits, standard operating procedures, meeting minutes, risk assessments and recently reported incidents.

After the inspection we requested further documentary evidence to support our judgements including training records, staffing roster, reports, and quality improvement initiatives.

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 24 October 2018

• The service gathered and acted on safety information. This information was shared with staff, patients and visitors and improvements were made where necessary.
• The service provided care and treatment based on national guidance. Managers checked to make sure staff followed guidance. There was a good amount of auditing taking place and the hospital performed well against England averages in its national auditing programme.
• The service was responsive to people’s needs. Vulnerable people had their needs met and there was good access to specialist staff and support services.
• Staff were passionate about the care they provided to patients. There were many examples of how staff had cared for patients in line with their needs and wishes. Patients and their families were involved in developing care plans and given information to help them understand choices available to them.
• There was a good local leadership team who were working within clear governance structures to provide assurance on the quality of service being provided. Staff were open and honest and worked well together.

However:

• Medicine management practices were not implemented effectively to ensure patient safety. Temperature recording was not taking place in drug storage rooms and where drug refrigerator temperatures went out of range action was not taken to ensure this was remedied.
• Staff did not have access to competency training or regular clinical supervision and staffing in some areas was not being maintained to keep people safe. Not all staff had an up to date appraisal.
• The hospitals escalation ward, Pear Tree, was not being used effectively. We found that a patient had been admitted to this ward outside of the admission criteria, records were not completed appropriately, staffing was inconsistent and there was a lack of equipment to meet people’s needs. There was also no quality monitoring taking place on this ward.
• The hospitals short stay unit was short staffed and patient care and appropriate record keeping was being impacted negatively.
• There was confusion about specific roles and responsibilities in discharge planning. Recent changes to the discharge planning team and additional responsibilities given to nursing staff had led to disjointed working. There was a high level of delayed transfers of care when compared to the England average.

Updated 20 December 2019

This is the first time we rated this service. We rated it as requires improvement because:

• The service provided mandatory training in key skills to all staff however not all staff had completed required training.
• Staff had training on how to recognise and report abuse, and they knew how to apply it. However, compliance with safeguarding training failed to meet the trust’s target.
• The service did not have enough nursing, medical and support staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. However, managers regularly reviewed and adjusted staffing levels and skill mix, and gave bank and agency staff a full induction.
• There was a lack of transition services and support in place. Staff did not have access to transition plans used to support young people moving on to adult services.
• Leaders were in the process of establishing governance processes, which were in their infancy at the time of our inspection due to recent implementation of the service.
• Not all risks were effectively documented and overseen. The lack of access to transition services and oversight of mandatory training compliance were not documented on risk registers.
• The service’s vision was in its infancy at the time of our inspection due to recent implementation of the service.

However:

• The service controlled infection risk well. Staff used equipment and control measures to protect children, young people, their families, themselves and others from infection. They kept equipment and the premises visibly clean.
• The design, maintenance and use of facilities, premises and equipment kept people safe. Staff were trained to use them. Staff managed clinical waste well.
• Staff completed and updated risk assessments for each child and young person and took action to remove or minimise risks. Staff identified and quickly acted upon children and young people at risk of deterioration.
• The service provided care and treatment based on national guidance and evidence-based practice. Managers checked to make sure staff followed guidance. Staff protected the rights of patients subject to the Mental Health Act 1983.
• Doctors, nurses and other healthcare professionals worked together as a team to benefit children, young people and their families. They supported each other to provide good care.
• Staff treated children, young people and their families with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
• Staff provided emotional support to children, young people and their families to minimise their distress. They understood patients’ personal, cultural and religious needs.
• Staff supported and involved children, young people and their families to understand their condition and make decisions about their care and treatment. They ensured a family centred approach.

Updated 24 October 2018

We rated this service as requires improvement because:

• There were equipment and environment concerns with patient rooms containing ligature risk blind pulls and equipment on the central venous pressure trolley out of date airway or missing.
• We were not assured that learning from medications incidents was embedded.
• Medical staffing remained a concern and did not comply with Guidelines for the Provision of Intensive Care Services (GPICS) 2015, as there were not enough consultants with intensive care qualifications.
• There was a potential risk that the service’s ability to provide care and treatment based on national guidance was compromised by using out of date and unratified guidance documentation.
• Step down care was impacted by patient flow on the wards which contributed to delayed discharges and discharges direct to home from the CCU.
• There was a gap in service provision between the CCOT finishing and the night medical team starting and this was rated as a significant risk on the department risk register.
• Leadership was inconsistent with key service managers and lead staff relatively new in post and senior and executive level visibility poor. There was no formal lead for the CCOT.
• Governance and risk management was inconsistent and not embedded within the CCU department.
• The service vision for what it wanted to achieve for its critical care service was not developed with involvement from staff and the majority of key staff were not aware of it
• There was limited evidence of the sharing of information from ‘board to ward’ and ‘ward to board’ with team meeting minutes devoid of governance information.
• Staff engagement was variable with some staff openly embracing the opportunities presented by cross site working. Other staff were less engaged citing ‘they felt the hospital had been taken over’ and that they had lost their ‘Hinchingbrooke identity’.

However:

• The service had state of the art purpose, built premises and equipment was well stocked and readily available for the service. All clinical practice areas were visibly clean and tidy and staff adhered to good hygiene practices.
• Staff recognised and reported patient safety incidents, shared lessons learned. When things went wrong, staff apologised and gave patients honest information and suitable support.
• Staff kept clear, up-to-date appropriate records of patients’ care and treatment which were available to all staff providing care.
• Staff collected safety information and shared it with staff, patients and visitors.
• Staff cared for patients with compassion. Feedback was extremely positive from patients who confirmed that staff treated them well with dignity and with kindness.
• Staff took time to interact with people who use the service and those close to them in a respectful and considerate way and involved patients and those close to them in decisions about their care and treatment.
• The CCU had a room where relatives could sleep overnight if necessary and a peaceful garden space, opened in November 2017, to provide a quiet, reflective space for the families of patients in critical care.
• Nursing staff were competent and the service provided good opportunities for learning and professional development.
• There was good multidisciplinary working within the staff groups The service provided good opportunities for learning and professional development. Doctors, nurses and other healthcare professionals supported each other to provide good care.
• Staff always had access to up-to-date, accurate and comprehensive information on patients’ care and treatment.
• The trust contributed to the Intensive Care National Audit Research Centre (ICNARC). Outcomes of care delivered and patient mortality rates at the trust were similar to the national average.
• The service offered monthly rehabilitation clinics which met national guidance requirements to provide support following discharge run by a consultant and a member of the critical care outreach team (CCOT).
• The service flexed beds to meet the differing clinical needs of level two, level three and acute cardiac patients.
• The service took account of patients’ individual needs and had access to other link services such as a specialist learning disabilities nurse and the mental health team for support.
• Staff were committed to providing quality care to their patients and supported each other.
• The CCU engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.

Updated 24 October 2018

We rated this service as good because:

• The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately.
• The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
• The nurse staffing for the specialist palliative care team (SPCT) was in line with national guidance.
• The trust had suitable premises and equipment and looked after them.
• The service provided care and treatment based on national guidance and evidence of its effectiveness, where the organisation did not meet clinical indicators there were actions from audits in place.
• Staff in the SPCT informally monitored their response times, preferred place of death and preferred place of care, and audited this data.
• Staff treated patients with compassion, dignity and respect. Feedback from patients confirmed that staff treated them well and with kindness.
• Staff involved patients and those close to them in decisions about their care and treatment. The service had open visiting hours, enabling relatives and carers to stay overnight and made arrangements to meet each individual’s needs.
• Staff provided emotional support for patients to minimise their distress. The trust gave patients and carers information on what to expect following the death of a loved one, and sign posted families to relevant information and support, including counselling services provided by external providers.
• The trust planned and provided services in a way that met the needs of local people. The trust had a system in place to highlight patients who were at the end of their life by placing a swan magnet around their bed space and on the ward white board for ease of identification and discussion at board round.
• The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff. All complaints relating to end of life care were reviewed by the SPCT and discussed at the end of life steering group meeting. Staff were aware of themes in complaints around end of life care and could identify areas of learning.
• The end of life care service had a strong, visible person-centred culture. Staff were highly motivated and inspired to offer care that was kind and promoted people’s dignity. We found strong caring, respectful and supportive relationships between people who used the service, those close to them and staff. However:
• The trust's ‘do not attempt cardio-pulmonary resuscitation’ (DNACPR) forms were not completed in line with trust policy or national best practice guidelines. We were not assured that the Mental Capacity Act and Deprivation of Liberty Safeguards were always implemented for people who had do not attempt cardio pulmonary resuscitation (DNACPR) documentation.
• Documentation around preferred place of death was poor, and not all patients had a preferred place of death recorded. Between February 2017 and January 2018, 64% of patients did not have their preferred place of death recorded.
• A high proportion of patients were too unwell to discuss their preferred place of death, indicating delays in referrals to the hospital specialist palliative care team.
• The trust did not audit how long it took to discharge patients to their preferred place of death. This was an area of improvement identified at the 2016 inspection, to ensure a clear target for fast track discharge of patient requiring end of life care and ensure a consistent monitoring of the timeliness of these discharges.

Updated 8 June 2023

Updated 24 October 2018

We rated this service as good because:

• Staff recognised incidents and reported them appropriately.
• Managers investigated incidents and shared lessons learned with the whole team and the wider service.
• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
• The service provided mandatory training in key skills to all staff and made sure everyone completed it.
• Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• The service provided care and treatment based on national guidance and evidence of its effectiveness.
• Staff cared for patients with compassion.
• Waiting times from treatment were and arrangements to admit, treat and discharge patients were in line with good practice.
• The trust engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.
• The trust was committed to improving services by learning from when things go well and when they go wrong, promoting training, research and innovation.

However:

• All departments within this service except one, prescribed, gave, recorded and stored medicines well.
• All departments within this service except one, had good governance processes around the use and storage of prescription pads.
• Not all managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service.

Updated 24 October 2018

We rated this service as good because:

• The service used safety monitoring information to improve the service and shared this information with staff and patients, through both the NHS safety thermometer and the internal ‘matron’s balanced score card’.
• The service had suitable premises and equipment and looked after them well.
• The service prescribed, gave, recorded and stored medicines well. Patients received the right medication, at the right dose, at the right time.
• There were measures in place to assess and respond to patient risk in a timely manner.
• There was a strong focus on safeguarding processes and staff knew how to recognise and report abuse.
• The service provided mandatory training in key skills to all staff and made sure everyone completed it.
• The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. Where there were unfilled shifts, the service used a core group of bank, agency and locum staff with the appropriate competencies to treat patients safely. Staff across surgery services reported timely access to consultants, if required.
• The service provided care and treatment based on national guidance and participated in national and local audits to benchmark its performance and identify areas for improvement.
• The service had achieved an ‘outstanding’ rating for general surgery and cancer in the 2018 ‘Getting It Right First Time’ (GIRFT) report. Clinical leads told us they were particularly proud of achieving the highest rate of complication-free day case surgery in the country.
• Staff assessed and managed patients’ pain well, and staff assessed and met patients’ nutrition and hydration needs, including making adjustments for patients’ religious, cultural and other preferences.
• Staff received regular appraisals to ensure they had the skills and competencies to carry out their roles, and there were opportunities for staff to undertake additional training and development, for example in breast care and catheterisation.
• There was strong multidisciplinary team (MDT) working, both internally and externally.
• Staff understood their roles and responsibilities under the Mental Capacity Act 2005 and mental capacity assessments were carried out appropriately.
• Staff were kind and compassionate in their interactions with patients and relatives and patients reported they were happy with the care they had received. Staff took the time to ensure patients understood and were involved in their care.
• There were measures for supporting patients’ emotional needs, including an ‘end of life companion’ volunteer support service.
• The trust planned and provided services in a way that met the needs of local people. Access and flow through the service was well managed, with support from a discharge planning team.
• The service took account of patients’ individual needs and used resources to meet these needs. For example, there were link nurses for dementia, learning disabilities, tissue viability, diabetes and wound care.
• There was strong local leadership and staff felt local leaders provided the support and guidance they needed.
• The service had a vision for what it wanted to achieve and workable plans to implement their vision. Plans had been developed with involvement from staff, patients, and key groups representing the local community.
• There was evidence of a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
• There was an effective ‘ward to board’ governance structure and a systematic approach to improving the quality of surgery services.
• There were effective systems for identifying and managing risks.
• The service engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.

However:

• Systems and processes for sharing learning were not consistent across the surgery service which meant there was a risk that potentially avoidable incidents could reoccur, due to action plans or important lessons not always being shared effectively between different wards or theatres.
• The service was not auditing the length of time between screening and treatment times for sepsis.
• Planned night staffing levels on Mulberry ward at night meant there was a risk that in the event of unexpected patient risk or deterioration, staff may not be able to access support promptly, although this ward used criteria aimed at admitting lower-risk patients.
• The 90% target for mandatory training compliance was not met for any modules for either medical or nursing staff within surgery, from June 2017 to May 2018.
• Staff on surgical wards reported concerns with timely access to patient records due to issues with the transfer of records from the A&E department to wards.
• One side room on the acute trauma and surgical unit (ATSU) had a visible gap in the door when closed which meant it was not best suited for preventing the spread of airborne infections.
• Local audit within the theatres department was more limited than on the wards meaning they could miss the identification and improvement of specific quality aspects.
• The service did not always investigate and close complaints in line with their complaints policy, which stated complaints should be completed within 30 days.
• Staff on the wards and in theatres felt that although divisional leads were visible and accessible, the trust senior team did not have a strong presence in clinical areas.

Updated 24 October 2018

• Staff did not routinely complete the patient safety checklist and carry out patient risk assessments when they should be, for example, pressure ulcer assessments were lacking in our review of medical records. Medical records lacked completeness and pertinent risk assessments. This meant that risks posed to patients was not always effectively identified.
• The emergency departmental (ED) staff team compliance for mandatory training was below the 90% target set by the trust for all areas except equality, diversity, and human rights at 92%.
• The ED staff team compliance for safeguarding adults training was below the 90% target set by the trust. The hospital diverted all visitors through the ED reception after normal operating hours and closed the main hospital doors. The trust did not employ security personnel in the ED and reception staff we spoke with told us they felt this felt unsafe during these times.
• There was a dedicated room within the ED for mental health assessments. However, the environment was not in line with the Royal College of Emergency Medicine (RCEM) mental health tool kit for improving care in emergency departments, which states any assessment area needs to be safe for staff, and conducive to valid mental health assessment and importantly, the assessment room must be safe for both the patient and staff.
• We noted throughout our inspection that children often sat in the adult waiting areas, this was not in line with national guidance which states that children and adults should be audio visually separated in ED environments.
• The department did not have a protocol for an upper gastro-intestinal bleed and severe haemorrhage or a rota for this process. The inability to manage high risk ‘emergency bleed’ patients in a timely fashion was on the trusts risk register and last reviewed in May 2018.
• Staff did not consistently monitor and record medication fridge temperatures to ensure medicines were stored in a safe manner to protect their integrity.
• 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 emergency department. Data supplied by the trust following inspection showed that from April 2017 to March 2018, the trust consistently failed to meet the standard and performed generally worse than the England average for the same period.
• From April 2017 to March 2018, the median total time in the emergency department, for all patients, was higher than the England average.
• Patients arriving by ambulance, had a dedicated route into the department, and ambulance staff reported to a streaming and triage process area. We observed a lack of command and control in this area.
• We reviewed nine patient pathways within the ED and all were out of date for review, most of these pathways were due for review in March 2017, therefore overdue for review. This included febrile seizure pathway, gastroenteritis pathway, head injury pathway, painful swollen joint or limp pathway, and unwell children pathway amongst others.
• The design and layout of the ED reception and ambulance handover area meant that conversations between staff regarding patients could be overheard, and did not promote privacy of information. The Royal College of Emergency Medicine recommends that the time patients should wait from time of arrival to receiving treatment should be no more than one hour. The trust did not meet this standard for any of the 12 months from April 2017 to March 2018.
• Most of the leadership roles within the emergency department (ED) were new at the time of our inspection. All the staff we spoke with felt that leadership and management had improved in the weeks leading up to our inspection; however, staff said that in the previous 12 months there had been little in terms of leadership of the department.
• Governance and risk systems and processes were not embedded within the department. Whilst the trust had a risk register and risks relating to the ED, most of the front-line staff did not know the risks or their impact.

However:

• Staff understood their responsibilities to identify and report incidents and safeguarding concerns.
• Staff from various teams worked well together as a team to monitor and improve patient care and outcomes.
• Patient feedback was positive, describing staff as ‘kind and caring’.
• Staff described a developing positive culture within the emergency department, telling us they felt supported and developed in their role.
• To improve mandatory training compliance the trust provided an experienced band seven ED sister as a clinical educator who spent two days each week in the ED at Hinchingbrooke Hospital.
• Staff maintained and checked resuscitation, sepsis, and airways trolleys on a daily basis, and we found these well maintained with no gaps in staff records.
• We reviewed the notes of three children in relation to PEWS, staff triaged the children within fifteen minutes of arrival, complying with the standards for children, and young people in emergency care settings set by the Royal College of Paediatrics and Child Health (RCPCH 2012).