Royal Berkshire Hospital

Letter from the Chief Inspector of Hospitals

Royal Berkshire Hospital is the main acute hospital for the Royal Berkshire NHS Foundation Trust, which provides acute medical and surgical services to a population of 600,000 people across Reading, Wokingham and West Berkshire, and specialist services to a wider population across Berkshire and the surrounding borders. The Royal Berkshire Hospital is the only site that provides inpatient provision overnight. The trust also has five other sites including West Berkshire Community Hospital, Windsor Dialysis Unit, Prince Charles Eye Unit, Royal Berkshire Bracknall Clinic and Townlands Hospital Outpatients.

During the inspection, in addition to the Royal Berkshire Hospital site, we visited West Berkshire Community Hospital (Day Surgery Unit and Outpatient services), Windsor Dialysis Satellite Unit and Prince Charles Eye Unit.

We carried out this comprehensive inspection because the Royal Berkshire Hospital NHS Foundation Trust was initially placed in a high risk band 1 in CQC’s Intelligent Monitoring system. However, when the latest Intelligent Monitoring bandings were updated the trust was placed in a low risk band 5. The inspection took place between 24 and 26 March 2014 and an unannounced inspection visit took place on 29 March and 2 April 2014.

Overall, this hospital requires improvement. We rated it ‘good’ for being caring and effective, but it requires improvement in providing safe care, being responsive to patients’ needs and being well-led.

We rated A&E, end of life care and services for children and young people as good, but we rated outpatients, medical, surgical, maternity and critical care as requiring improvement. Our key findings were as follows:

• Staff were caring and compassionate and treated patients with dignity and respect.
• The hospital was clean and well maintained, although there were some examples where cleanliness fell below expected standards.
• The workforce were committed and we noted an open culture during the inspection.
• Infection control rates in the hospital were similar to those of other trusts except the C.Difficile rates, which were higher than average and the trust was taking steps to make improvements.
• Staffing levels were not always sufficient to meet the needs of patients on all ward areas, with a consequent reliance on bank and agency staff.
• Medical records and the electronic patient record system and processes were not robust, which resulted in patient records not being available, reliance on temporary records and inability to access records as required in a timely manner, which impacted on the ability to deliver care.
• Critical care capacity was insufficient and operations were going ahead when there had been a potential need for critical care post-surgery identified and no critical care bed was available.
• The observation ward in A&E was a room with three beds but it was not included in the four-hour decision to discharge, admit or treat A&E target as it was used as a ward, although it did not have any shower facilities. There were concerns about appropriate use and care of patients in this observation area.
• The major incident process associated with decontamination was not appropriate because of the distance and journey for patients through the hospital.
• Safeguarding processes and knowledge of the Mental Capacity Act was not sufficient.
• DNACPR forms were not consistently completed.
• The end of life care team worked collaboratively with key stakeholders.
• Paediatric care was generally positive.

We saw several areas of outstanding practice including:

• Caring interventions and support for families in the Intensive Care Unit.
• The Children’s A&E department.
• Consultant geriatricians worked in the A&E department 8am to 8pm seven days a week.
• The responsiveness of the Palliative Care team.

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

Importantly, the trust must:

• Ensure that medical records are kept securely, and records can be located and accessed promptly when needed to appropriately inform the care and treatment of patients.
• Maintain the privacy and dignity of patients placed in the observation bay in the A&E department.
• Ensure that the design and layout of the emergency department protects patients and staff against the risks associated with unsafe or unsuitable premises.
• Take appropriate steps to ensure that, at all times, there are sufficient numbers of suitably qualified, skilled and experienced staff employed to care for patients’ needs, and safeguard their health, safety and welfare.
• Accurately complete ‘Do not attempt cardio-pulmonary resuscitation’ (DNA CPR) forms, and document the discussions about end of life care with patients.
• Take proper steps to ensure that each patient is protected against the risks of receiving care or treatment that is inappropriate or unsafe by planning the delivery of care and appropriate treatment meet the patients’ individual needs and have procedures in place to deal with emergencies which are reasonably expected to arise.
• Review the ICU capacity across the trust; employ suitably qualified, skilled and experienced staff; and have necessary equipment available to care for patients who require intensive or high dependency care.
• Ensure that planning and delivery of care meets patients’ individual needs, and ensure the safety and welfare of all patients.
• Increase staff knowledge of Deprivation of Liberty Safeguards (DOLs) and the Mental Capacity Act (MCA) through necessary training to improve safeguarding.
• Improve contemporaneous record keeping by all staff to avoid misplacing records of care and observations.
• Ensure the staffing levels and admission criteria in the Rushey Midwife-led unit is maintained to ensure safe care is provided to all women.
• Ensure that at all times there is a sufficient number of suitably qualified, skilled and experienced staff employed to provide safe midwifery care in all areas.
• Take action to improve the ventilation system on the delivery suite, to protect patients and others who may be at risk from the use of unsafe equipment.

In addition the trust should:

• Ensure patient flow and discharge enables patients in the A&E to be admitted to wards without undue delay.
• Ensure patients are supported with access to information in a language that meets their needs throughout the hospital.
• Ensure that staff are appropriately trained to care for patients with dementia.
• Improve the visibility of the executive team throughout the hospital and be open with the workforce regarding the strategic direction for the trust.
• Ensure that all equipment is properly checked, maintained and documented with sufficient equipment available to meet needs of all patients.
• Utilise the Intensive National Audit and Research Centre Case Mix programme (ICNARC data) to drive improvements and meet standards of care.
• Ensure a regular programme for changing disposable curtains.
• Ensure that appropriate risk assessments are undertaken where patients remain in the A&E department for a prolonged period.
• Ensure that shift lead handovers in A&E take place without interruptions to ensure prompt communication.
• Ensure that access to CAMHS services are timely and meet the needs of patients.
• Ensure that access to equipment for use in chemical biological or hazardous incidents is easily accessible.
• Ensure all staff are aware of the process to raise concerns in accordance with trust policy.
• Ensure that communication to GPs following a consultation or inpatient stay is consistently documented and sent in a timely way.
• Review transition processes for young people with all long term chronic conditions.

There were also areas of practice where the trust should take action which are identified in the report.

Professor Sir Mike Richards

​Chief Inspector of Hospitals