Archived: Ipswich Hospital

Updated 18 January 2018

Ipswich hospital NHS Trust provides acute, maternity and community health services across the following locations; Ipswich hospital, Gilchrist birthing unit, Foot and Ankle Surgery centre, Aldeburgh community hospital, Bluebird Lodge community hospital and Felixstowe community hospital.

Acute services are provided at Ipswich Hospital and encompass urgent and emergency care, planned medical and surgical care, critical care, consultant and midwifery-led maternity, neonatal and paediatric care, end of life care and diagnostic and therapy services. Community hospitals and specialist community services were taken on by the Trust in October 2015.

We carried out a comprehensive inspection at Ipswich Hospital NHS Trust, as part of our comprehensive inspection programme under CQC next phase methodology (2017). We carried out unannounced inspections of five core services; urgent and emergency care and services for children and young people were inspected on 31 and 31 August 2017. We inspected end of life care and medical services on 19 and 20 September and community inpatients on 21 September 2017. We then carried out an announced well-led inspection on 12 and 13 October 2017.

To get to the heart of patients’ experiences of care, we always ask the following five questions of every service and provider:

• Is it safe?

• Is it effective?

• Is it caring?

• Is it responsive to people’s needs?

• Is it well-led?

We decide all ratings using a combination of aggregating the core service ratings and the professional judgement of inspection teams. We provide ratings at different levels and we use a set of ratings principles to help us to determine the final ratings. The inspection report will specify the date when we awarded the rating for each service. If we have not inspected a core service or key question as part of the trust inspection, we will maintain the existing rating. Aggregated ratings will be a combination of previously allocated and new ratings from recent on-site inspection activity.

Before inspecting we reviewed a range of information we held about the provider, including Insight dashboard information. We engaged with the provider and engaged with stakeholders to share what they knew about the hospital. These included the clinical commissioning group (CCG), Quality Surveillance group (QSG) which includes NHS England; NHSI, Health Education England (HEE) and Healthwatch.

Following this inspection we will make sure that the trust takes the necessary action to improve its services. We will continue to monitor the safety and quality of services through our continuing relationship with the trust and our regular inspections.

Updated 18 January 2018

The Care Quality Commission (CQC) carried out a comprehensive inspection between the 6 and 8 January 2015. We also carried out unannounced inspections on 12 and 15 January 2015.  We carried out this comprehensive inspection at Ipswich Hospital as part of our comprehensive inspection programme. Ipswich Hospital is part of Ipswich NHS Trust which was rated as being in band six of our intelligence monitoring tool and was therefore a low risk.

The hospital was first built around 1910, and has been expanded to cover 45 acres. The newest addition is the private finance initiative (PFI) wing, opened in 2007. The hospital serves around 385,000 people from Ipswich and East Suffolk. It has a relatively high deprivation score, being 83rd out of 326 (1 being the worst), and deals with significantly higher levels of depression and people living with dementia than average. There is also a higher than average number of young people with drug and alcohol-related health problems. However, the population that the trust sees has a higher than average life expectancy. We found that the trust had a relatively new executive team, who worked effectively together to highlight issues and address challenges within the hospital. We found the trust management team to be responsive and to act quickly to address issues highlighted to them during our inspection. The trust were aware of the issues of poor leadership faced on Sproughton Ward and highlighted this prior to our site visit. We also identified challenges on this ward, including poor documentation and a differing patient group than had originally been planned for this ward, and the trust took action overnight to ensure that people received safe and effective care in this ward. We returned to this ward during our announced and unannounced inspections, and found that improvements made had been sustained.

The comprehensive inspections result in a trust being assigned a rating of ‘outstanding’, ‘good’, ‘requires improvement’ or ‘inadequate’. Each section of the service receives an individual rating, which, in turn, informs an overall trust rating. The inspection found that overall, the trust has a rating of 'Good.

Our key findings were as follows:

• 'Never events' that had occurred were actively and imaginatively investigated, including using human factors analysis, and lessons were learnt.

• Systems in place within the emergency department were assisting to effectively tackle the Winter pressures during our inspection.

• Staff were caring and compassionate, and treated patients with dignity and respect.

• The hospital was visibly clean and well maintained. Infection control rates in the hospital were lower when compared with those of other hospitals.

• The trust performed better than average in a number of national audits, including the national hip fracture audit, the national bowel cancer audit, the national lung cancer audit data, the Sentinel stroke national audit, and the myocardial infarction national programme.

• Managers and staff responded quickly and took appropriate actions to ensure patient safety where we identified issues on one ward within the medical service.

• The trust had an ongoing recruitment and retention programme to address staffing shortfalls.
• The equipment within the diagnostic centre was aged, and whilst it was noted on the vision for the service that equipment was nearing end of its life, there were no plans or timeframe formally in place to upgrade equipment.
• The critical care pathway for children was not well defined. Improvement was needed with regards to the provision of a children’s high dependency unit (HDU).

We saw several areas of outstanding practice, including:

• The emergency department trigger tool, which was in place to ensure that the responsiveness of the emergency department was maintained when the department was beginning to see increasing pressures.
• The chaplaincy service carried a trauma bleep in order to provide emotional support to relatives of trauma victims.
• Ipswich Hospital was one of only two trusts to participate in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), providing international benchmarking of patient outcomes.
• There was a comprehensive outreach service in place, providing full 24/7 cover including a 'patient activated' referral for the team.

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

Importantly, the trust must:

• Review the end of life care paperwork to ensure that it is more individualised and providing a holistic approach in line with National Institute of Health and Care Excellence (NICE) guidelines.
• Provide training to staff providing end of life care, on how to identify patients approaching the end of life, and on how to use the new care plans.
• Ensure that discussions with patients and families regarding end of life care, or advanced care planning decisions, are clearly recorded in the person’s medical records.
• Ensure that prior to undertaking a procedure, or completing an end of life care order, the person’s mental capacity is appropriately assessed in accordance with the Mental Capacity Act 2005.
• Ensure that all clinical areas in outpatients, including the equipment in rooms, are cleaned regularly, and the cleaning is evidenced.
• Ensure that the decontamination room in ear, nose and throat (ENT) outpatients is compliant with guidelines on decontamination Hospital Technical Memorandum.
• Review medicines management in the South Theatre areas to ensure medicines are stored securely.
• Clearly define a critical care pathway for children and review the provision of services for children requiring high dependency of care, including staffing numbers, competency and provision of registered sick children’s nurses (RSCN).

There are areas where the trust should consider action, including:

• Review reporting incident mechanisms within the surgery division, including reviewing working arrangements to help facilitate timely reporting.
• Review monitoring equipment within surgery, with a view to standardising the equipment available.
• Review service planning and delivery within maternity, to ensure actions for service development are in line with current clinical practices, and consider the requirement of specialist lead roles.
• Ensure governance procedures and risk registers are active and maintained in children’s services and critical care, and ensure a robust system of audit, including patient outcome monitoring, to improve learning.
• Review the staffing levels for the palliative care, mortuary and chaplaincy service, to ensure that there are sufficient staffing levels to meet the demand for services.
• Review the audit tools used for end of life care, including 'do not attempt cardio-pulmonary resuscitation' (DNA CPR) forms, to ensure that they are more dynamic to improve learning.
• Ensure that a full review of staffing in diagnostic services is undertaken, to ensure that current staffing levels versus service demands is achievable.
• Develop and agree a reasonably timed plan for the refurbishment and upgrade of diagnostic machines, to ensure that the images meet the NICE guideline requirements.
• Review working arrangements to share learning and information across the outpatient services between the three divisions.
• Ensure that waiting times are clearly displayed in the outpatients department, to ensure that people are informed of up-to-date delays to appointments when they attend clinic.
• The trust should consider ways in which waiting times could be reduced within the outpatient department.
• Ensure that pain relief is offered to patients in the fracture clinic.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Updated 18 January 2018

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

• The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
• The service used safety-monitoring results well and provided care and treatment based on national guidance and evidence of its effectiveness.
• The service took account of patients’ individual needs. Staff of different kinds worked together as a team to benefit patients. There was a strong culture of multidisciplinary staff working.
• The trust had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care.

However:

• Medical records were not always secure as these were stored in unlocked trolleys.
• There was inconsistency between electronic and paper based records of venous thromboembolism (VTE) assessments.
• There was limited access to the acute psychiatric pathway and therefore delays in psychiatric assessment were an issue on the inpatient wards.

Updated 18 January 2018

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

• The service now had enough trained staff and clear clinical leadership for the provision of high dependency care.
• The critical care pathway for children was now more defined. There was clarity around patient flow and expectations of staff when a patient may require critical care provision.
• Incident management was robust. Staff not only understood how and when to report incidents, but were now also informed regarding learning and improvement from incidents.
• An annual audit plan was in place for the service which received management and monitoring from the audit department and had oversight by a named consultant. Whereas previously there had been a lack of initiatives to measure and monitor patient outcomes.
• Both internal and external multidisciplinary (MDT) working was evident throughout the service.
• Compassionate care was consistently observed and noted by patients and their families, and privacy and dignity were well highlighted throughout the service.
• Several support groups were established offering specialist advice to patients and their families. The Voice4Change young people’s group was a finalist in the Patient Experience Network national awards.
• There was a portable sensory suite available. This provided a range of programmes to stimulate and provide enjoyment for all children, including those with additional needs.
• There was an improved governance system with increased staff awareness of identifying risks, and planning to reduce them. Staff were committed to improving services with innovation evident throughout the service.

However:

• Not all mandatory training, including safeguarding children level three, met the Trust target.
• Medication management and oversight of the temperature requirements for medication storage was inconsistent across the service.
• There was poor completion of the ‘First hour of care’ documentation on the neonatal unit by medical staff.
• There was no lead for the transition pathway for adolescents moving on to adult services. Transition was ad hoc. This was acknowledged by the trust however, plans to address this were in their infancy.
• Involvement of parents in ward rounds on the neonatal unit was not wholly transparent. Babies would be seen without their parents, with parents being brought into discussions at the end of the medical review of their baby, and updated on their care.
• There was no separate paediatric recovery area for children who had undergone day surgery and paediatric recovery nurses were not always available.

Updated 10 April 2015

Critical care services were safe, effective, caring and responsive to meet the needs of patients and relatives, and the service was well-led. Staff cared for patients with compassion, dignity and respect. Good quality outcomes were evident, and patients received treatment that was based on national guidelines. The overall capacity was adequate, and patients received timely care and admission to the unit; however, delayed transfers out of hours were high due to the unavailability of step down beds on the wards.

Medical and nursing staffing levels were planned, implemented and reviewed depending on patient acuity and turnover, and adhered to national guidance.

Staff competency and training arrangements were embedded, resulting in a supportive environment, and staff morale was good.

Service provision for children was primarily stabilisation prior to transfer; however, the unit treated approximately 20 children a year. There was no written policy for paediatrics in place, and no registered sick children’s nurse (RSCN) employed on the intensive care unit (ICU).

The management at service level on the nursing side were clear about their roles and vision for the service; however, this was not as embedded within the medical team. The governance and risk management within critical care was not embedded. During our inspection we identified a number of aspects of care where risks had been identified; however, there were no current risks on the risk register. An example of this was the paediatric patients on the ITU. Therefore, there was no assurance that timely actions were being taken to protect people from avoidable harm.

Updated 18 January 2018

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

• The service had enough staff with the right qualifications, skills, training and experience. The nurse staffing for the specialist palliative care team (SPCT) was now in line with national guidance.
• The service managed patient safety incidents well. Staff knew their responsibilities around reporting incidents and shared learning from incidents related to end of life care.
• Staff kept appropriate records of patients’ care and treatment. The symptom assessment tool had been improved and there were now individualised care plans which were in line with national guidance.
• Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) forms were mostly well completed. Records of discussions with patients and relatives, signed by a senior clinician, had improved.
• Staff at the service treated patients with compassion, dignity and respect and involved them in their care. All patients we spoke to were positive about the care given by staff.
• The trust had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care. The director of nursing was the executive lead for end of life care and there was now a named non-executive director with responsibility for end of life care.
• The end of life care strategy included defined local priorities, outcomes and measures of success.

However:

• Staff in the SPCT informally monitored their response times but did not formally audit this. The trust did not audit preferred place of death or preferred place of care so were unable to measure the efficacy of the service.
• Patient’s mental capacity was not always clearly documented.
• There were sometimes delays in completion of death certificates and cremation documentation.
• Senior staff had limited oversight of incidents relating to end of life care across the trust and there was no risk register specific to end of life care.
• The mortuary was still in need of refurbishment.

Updated 10 April 2015

Maternity and gynaecology services provided to women and babies by Ipswich Hospital overall was good, with some improvements required in respect of the responsiveness of the service. There was a strong focus on patient safety and risk management practices. Mandatory training, including safeguarding measures, were in place, and staff recognised and responded appropriately to changes in risks to people who use services.

Staff were appropriately qualified and competent, and safe staffing levels and skill mix encouraged proactive teamwork, to support a safe environment. Individual care and treatment was planned and delivered in line with current evidence-based guidance.

Patient outcomes for maternity and gynaecology were good, as was the counselling support for women undergoing termination of pregnancy and those women suffering a miscarriage. Care provided was good, and patients were treated with dignity, respect and kindness.

Service planning and delivery required improvement, as actions for service development in line with current clinical practices were not always in place or proactive, as there was a lack of specialist lead roles.

 The midwifery leadership model encouraged co-operative, supportive relationships among staff, and compassion towards people who use the service. An open, honest and transparent culture was evident, with staff confident in the support of their managers and the senior executive team.

Updated 10 April 2015

Outpatient and diagnostic imaging services required some improvement. Not all areas of the outpatient services were visibly clean. The outpatient ENT department decontamination room was not fully Hospital Technical Memorandum compliant. The equipment within the diagnostic centre was aged, and whilst it was noted on the vision for the service that equipment was aged, the plans for replacement had only recently been signed off by the trust board. Due to the age of the equipment, NICE guidelines were not being met due to out-of-date software and hardware. This meant that whilst they were safe they could not deliver treatment and diagnosis in line with current guidance. Seven day working did not take place in outpatients or in diagnostic imaging. The care provided by staff to patients in the outpatient and diagnostic imaging services was good. The service was responsive, and patients were able to access their outpatient and diagnostic appointments in a timely way, with the trust performing well on the outpatient and cancer pathways. The service was well-led locally, although the structure of the outpatients department meant that there was no overarching outpatients lead, and there was a disconnect between how each outpatient service was run, because it was run by each division. Staff were proud to work at Ipswich Hospital.

Updated 10 April 2015

Surgery services at Ipswich Hospital were good; however, staff in East Theatre felt unable to report incidents due to time constraints, and believed the process to be too time consuming. Therefore, an open culture for raising safety concerns was not embedded throughout the division. This area require improvement.

Patients were monitored and reviewed promptly. Care and treatment given was evidence-based, and followed NICE guidelines. The surgical division had taken a robust approach to audit, and was benchmarking patient outcomes internationally by participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). Best practice learnings was shared across the trust.

Surgical services were planned, and surgery cancellation rates were low. The service was responsive to the needs of patients; patients were treated with compassion, kindness, dignity and respect.

The arrangement of surgical services across the site made for logistical problems and management challenges, resulting in varying leadership across the division.

Updated 18 January 2018

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

• The emergency department had processes in place to manage patient incidents. Staff identified incidents and reported them appropriately. Managers shared learning from the investigation of incidents and concerns with staff.
• Staff from different specialities worked effectively as a team and they had the required skills to treat patients presenting to the emergency department from minor injuries to major trauma.
• The department continually monitored performance both locally and nationally. These results were used to plan new services and improve existing services.
• Staff provided compassionate care to their patients tailoring care to the patient’s individual needs.
• The department had a positive staff culture and staff felt able to contribute ideas to improve the services provided.
• There were processes in place to communicate information from the emergency department to the board.

However:

• The trust did not have robust processes in place to ensure that equipment checking or testing was completed in a timely way.
• The completion of mandatory training by staff within the emergency department did not meet the trust completion target.
• There was no formalised assessment process to ensure that the area in majors used for mental health assessments was safe and suitable for use.
• The structure of the paper records did not help staff in identifying and recording all types of abuse.
• The department’s performance against national standards was variable.