Archived: Ipswich Hospital

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