All inspections: Conquest Hospital - Care Quality Commission

We inspected the maternity service at Conquest 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 a short notice announced focused inspection of the maternity service, looking only at the safe and well-led key questions.

The obstetric led unit at Conquest Hospital was part of the East Sussex Healthcare NHS Trust. The unit provides antenatal, postnatal, early pregnancy unit and obstetrics. Doctors were available 24 hours a day to perform epidurals for pain relief, assisted and emergency births. Women who had medical conditions, complications during their pregnancy for themselves and their baby were advised to give birth at the consultant led unit.

The unit had a 10-room delivery suite, 1 theatre and 2 recovery beds. There was 24-hour cover from obstetricians and anaesthetist to assist women. Elective caesarean section lists were on a Monday, Tuesday, Wednesday and Friday.

The postnatal ward has 3 bays of 4 beds, total 12 beds and 3 side rooms, total 15 beds. (4 postnatal beds are ring fenced where possible for transitional care).

The antenatal ward is co-located with the postnatal ward consisting of 8 beds in 2 bays. Induction of labour is undertaken in this area

The maternity day assessment unit has four beds for seeing women throughout each day. Triage was a telephone triage system and based within the Eastbourne midwifery unit based in Eastbourne Hospital.

From April 2021 to March 2022 there were 2937 births across all trust sites.

We did not rate this hospital at this inspection. The previous rating of outstanding remains.

We also inspected one other maternity service run by East Sussex Healthcare NHS Trust. Our reports are here: Eastbourne District Hospital, Eastbourne Maternity Unit: https://www.cqc.org.uk/location/RXC02

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 established key lines of enquiries (KLOES).

We visited all areas within the consultant lead maternity unit. We spoke with 11 women,15 staff members to understand what is was like working for the service, including consultants, anaesthetist, doctors, midwives, maternity care assistants and housekeepers.

We interviewed leaders to gain insight into the trust’s leadership and governance model of the service.

We reviewed 6 sets of patient care records. We also looked at a wide range of documents including standard operating procedures, meeting minutes, risk assessments and recently reported incidents.

After the inspection we requested further documentary evidence to support our judgements including policies and procedures, staffing rotas 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.

Conquest Hospital is a district general hospital, located in St. Leonards-on-Sea, on the outskirts of Hastings. It has surgical and medical wards and specialist units, a 24 hour Emergency Department and a full range of diagnostic services including Magnetic Resonance Imaging (MRI), Computer Tomography (CT) and Interventional Radiotherapy.

Emergency and high-risk general surgery takes place at Conquest Hospital and also complex planned operations.

Conquest Hospital also has a consultant-led maternity unit with a 10-room delivery suite and postnatal and antenatal wards.

Our rating of services improved. We rated it them as outstanding because:

We rated end of life care as outstanding and children and young people’s services and outpatients as good. We rated the key questions of caring and well led as outstanding overall, and safe, effective and responsive as good. In rating the trust, we took into account the current ratings of the five services not inspected this time

Our rating of services remained the same. We rated it them as requires improvement because:

The rating requires improvement was given because although all of the services we inspected in March 2018 had shown significant improvements, the rating is aggregated with the ratings from previous inspections which continue to be considered where we have not re-inspected.
Staffing continued to be a challenge. There were innovative roles created to mitigate some of the risks, there was ongoing recruitment and there was better use of in-house bank staff over agency staff. The only area where we saw an unacceptable impact was with the administrative and reception staff in the emergency department who felt unable to have any breaks during long shifts.

However:

We were aware from our ongoing monitoring of wider improvement in core services which were not inspected in March 2018. These improvements cannot be reflected in the ratings as they have not been corroborated trough inspection.
The ongoing monitoring and information we hold about Conquest Hospital, coupled with discussions with numerous staff, showed a cultural shift which resulted in a more motivated workforce and a commitment to improving the quality and safety of services. This was true across all areas of the hospital whether inspected at this inspection visit or not.
Incident reporting and learning from incidents was embedded in everyday practice. Monitoring and reviewing activity enabled staff to understand risks and gave a clear and current picture of performance and safety. The number of incidents reported had increased steadily since our inspection in October 2015 but the number of incidents resulting in harm had fallen. This demonstrated a good reporting culture.
Never events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. Each never event type has the potential to cause serious patient harm or death but neither need have happened for an incident to be a never event. From December 2016 to November 2017, the trust reported three incidents classified as never events. The trust had provided a robust response to all incidents to reduce the risk of recurrence.
Staff took a proactive approach to safeguarding and focussed on early identification and intervention. Staff from the Conquest Hospital were actively engaged in the local safeguarding arena and with other providers. Staff were trained to the appropriate level.
Risks to patients were assessed, monitored and managed on a day-to-day basis. This included observing for signs of deteriorating health, medical emergencies and challenging behaviours.
Peoples care and treatment was planned and delivered in line with current national guidance and legislation. There was ongoing monitoring to ensure that practice and policy remained in line with best practice guidance.
People had comprehensive assessments of their needs with consideration of their clinical needs, mental health and nutritional needs. Data provided showed improvements in assessing individual risks such as for venous thromboembolism (VTE). There was also a steady decrease in the incidence of falls with harm resulting from improved risk assessments.
There was good multidisciplinary working across services.
Consent was obtained in line with the current legislation and guidance including the Mental Capacity Act 2005, and the Children Acts 1989 and 2004. People were supported to make decisions and where appropriate their capacity to consent was assessed and recorded.
Infection prevention and control practice was much improved and there was data available to demonstrate that the hospital was routinely cleaned to an acceptable level in line with the National Specification for Cleanliness in the NHS.
There was a very person centred culture that had developed since our previous inspection in October 2015. Staff wanted to provide good care and were kind and compassionate in their interactions with patients. This was reflected in the results from the Friends and Family Test.
On previous inspection visit in October 2015 some staff were unclear about their line management arrangements and felt unable to raise concerns. There were several complaints to the inspection team about bullying. This had now changed. Staff reported approachable and supportive managers, clear lines of accountability and an executive and senior management team who were visible and who listened to frontline staff.
The governance processes were robust and understood by all. Work had been done to streamline the Risk and Quality Delivery Strategy that made explicit the lines of accountability and reporting systems. There was effective information sharing in both directions between the frontline operations and the board.
In medicine for the referral to treatment time (percentage within 18 weeks) - admitted performance. The performance of the trust was consistently better than the England average from December 2016 to November 2017.
The length of stay and waiting lists were in line with national standards and comparators

We inspected the Conquest Hospital as part of the East Sussex Healthcare NHS Trust inspection on 4,5 and 6 October 2016. The trust had been previously inspected in September 2014 and March 2015. On both inspections we identified serious concerns and gave the hospital an overall rating of inadequate. The trust was rated inadequate overall because the two location reports and the concerns that we identified across the trust relating to culture and governance. A Quality Summit which included all key stakeholder organisations was held in September 2015 and, following that meeting, I recommended that the trust be placed into ‘Special Measures’. This meant that the trust was subject to additional scrutiny and support from the local clinical commissioning groups and NHSI who provided an improvement director to advise and to monitor the implementation of action plans to address the shortcomings identified. The commission also maintained a heightened programme of engagement and monitoring of data and concerns raised directly with us.

This inspection was specifically designed to test the requirement for the continued application of special measures at the trust. Prior to inspection we risk assessed all services provided by the trust using national and local data and intelligence we received from a number of sources. That assessment led us to include six acute hospital services (emergency care, surgery, maternity and gynaecology, children and young people, end of life care and outpatients) in our inspection. The two other acute hospital services (medicine and critical care) and community services were not inspected as they had indicated good performance at previous inspections and our information review suggested that this had been sustained.

We did consider how medical services and the high number of medical patients impacted on patient flow and whether this affected other core services. We also visited medical wards as part of the review of end of life care.

We did not inspect community services as part of this inspection as they were currently rated ‘good’ overall. We did consider where new initiatives developed by the community services impacted upon the work of the two acute hospitals.

Following this inspection we have re-rated the services inspected. For other services we have maintained ratings from previous inspections. We have aggregated the ratings to provide an overall rating for the trust of requires improvement.Caring was rated as good, whilst safe, effective, responsive and well-led are all rated as requires improvement. This constitutes a significant improvement from the previous rating of inadequate.

.Our key findings were as follows: -

SAFE

The incident reporting culture had been significantly improved.
We saw clear evidence of learning from a Never Event with robust investigation and embedded changes to practice across the hospital.
Staff understanding of duty of candour had improved.
Infection control oversight had been significantly strengthened and hand hygiene practice was largely compliant.
We were able to see fledgling improvements in the provision of services trustwide with clear indicators of positive changes from data provided by the trust and from national data we hold at CQC about the trust.
Daily ‘Safety Huddles’ were being rolled out across the hospital. These encouraged the wider multidisciplinary team to share concerns and consider ways to improve the care of patients.
Where compliance with VTE risk assessment and prevention had been a concern in our previous inspection report, there was now evidence of high rates of compliance with 95% of patients having a properly completed VTE risk assessment in July 2016.
Safeguarding vulnerable adults and children was given sufficient priority.
Medicines management processes had been significantly improved.
The transfer of patients from ambulance to the emergency department was subject to delay and not being monitored.
There was a significant backlog in the reporting of x-ray examinations.
Record keeping was not consistent across the trust notably in the documentation of risk assessments within the emergency department and full completion of risk assessments in paediatric services.
Where electronic recording and escalation of observations had been introduced this had demonstrably improved the outcomes for patients.
Staff recruitment continued to be problematic with high levels of bank and agency use in some areas. There were departments such as the emergency department where the staffing arrangements were not in line with the national recommendations.

EFFECTIVE

Pain was managed well with new initiatives in the care of children and young people and better recording of pain scores across the hospital.
Stroke services had been consolidated at the Eastbourne site. A recent report issued by the Stroke Association in November 2016 showed that the hospital was providing good access to stroke services.
End of life care and emergency departments were not meeting national audit standards in some areas.
The assessment of mental capacity by staff remained inconsistent across the trust.
The wishes of patients about the upper limit of treatment when on an end of life care pathway was not always recorded. Staff had not always discussed the 'ceiling of care with patients or their families.
There were no services now rated as inadequate
Policies were largely up to date and referenced by best practice, with the exception of maternity services.
Surgery services were no longer an outlier for clinical outcomes.
Auditing programmes were more developed than on previous inspection visits but further work was needed to ensure that the full cycle of data collation being used to drive improvements needed further embedding.

RESPONSIVE

The emergency department indicated a deteriorating performance against access standards.
The trust was not maintaining the delivery of treatment to patients within 18 weeks of referral from GP's or within 62 days for patients referred onto a cancer pathway.
Patient flow through the hospital was challenged leading to patients being cared for in suboptimal clinical areas.
A Frailty Nurse Specialist team had been set up to work across the acute hospitals and community services to reduce the number of unnecessary admission (particularly from care homes) and to support patients who were best cared for in the community.
Patients on an end of life care pathway did not have access to a rapid discharge service.
The outpatients service was no longer rated as inadequate with significant improvements to the call centre.
The hospital staff tried to ensure that the individual needs and preferences of patients were met. Our previous report from September 2014 talked about staffing shortages and a culture that led to task focussed nursing care and a lack of consideration of individual needs. This was not something we observed on this inspection visit.
The trust was very responsive to meeting the complex needs of patients notably those living with dementia or learning disabilities.
Appropriately trained staff were not available to support children who were particularly anxious or in pain through play
Response times to complaints had improved significantly since April 2016. We saw evidence of appropriate responses to complaints, and learning from complaints and concerns. The trust had improved the way they responded to complaints as well as the response times.

WELL LED

No services were rated as inadequate for leadership.
The senior leadership was now sighted on operational and strategic issues and had clear and well considered plans for service improvement.
Staff told us that the executive team were much more visible around the hospital than they had been prior to the appointment of the new chair in January 2016 and new chief executive in April 2016.
Nursing staff also talked to us about the Director of Nursing (DoN) who was felt to be a consistent and steadying influence as the trust went through a period of significant change. Nurses said they trusted the DoN and felt she was ever present, approachable and understood the challenges at ward level.
The organisational culture had transformed since our last inspection. Staff were largely positive, well engaged and felt valued by the organisation. However, there were areas where staff were still feeling daunted by the changes and where morale was low. This was particularly the case with medical records and some administrative staff where the systems they worked with and, in some cases, their place of work had changed.
Governance had been significantly strengthened in terms of structure and the quality of board papers and data.This had led to a strong sense of accountability within the trust.
The senior team remains relatively new in constitution and some elements of governance and performance management have only recently been introduced
The trust was yet to complete the transition to a new operational structure.
At service levels our inspection identified some weaknesses in the management of risk and mortality.
Innovation was now encouraged and we saw several areas where staff had been encouraged and supported to introduce changes to bring about improvements in quality and safety. Staff felt more engaged in developing the service and were allowed more involvement in how services were provided.

We saw several areas of outstanding practice including:

Following the project lead midwife’s maternity review, the trust had introduced a programme of project groups related to maternity. These included the pilot scheme of a new homebirth and triage role for community midwives, and a perinatal mental health specialist midwife role.
A consultant orthopaedic surgeon had written a national guide for the Royal College of Surgeons on avoiding unconscious bias which was published in August. The guide focused on overcoming the unconscious opinions that everyone forms about people when they first meet them and offered advice to get beyond this. This national guidance referenced the trust’s Anti-bullying Policy in the Doctors’ Clinical Handbook and highlighted the progress and work made within the trust to address perceptions of bullying and harassment.
We saw an example of best practice for care provided to dental patients with special needs or learning disabilities.A multidisciplinary planning meeting was conducted in advance of the attendance. The appointment was used to provide one stop care including taking bloods, scans and giving the patient a haircut to minimise distress to the patient. There were a variety of options provided for location; aspects of care could be initiated in different locations such as properly supported sedation in the patient’s home and anaesthesia in the car park or in the hospital depending on the need.
A dedicated multidisciplinary team had established a five-year plan to establish an innovative rehabilitation care plan as part of an out of hospitals services transformation programme. This programme included staff from multiple specialties and enabled ED staff to work with colleagues from across the trust and in the community to develop future services, including an ambulatory rehabilitation unit and a rapid access care service. The programme planned to introduce nurse practitioner roles for frailty, crisis response and proactive care who would provide an integrated rehabilitation service alongside hospital and community-based specialists. This programme would significantly improve working links between the trust’s hospitals and local authority social care services and enable rehabilitation services to be provided more responsively to avoid the need for hospital admissions. There was significant support and infrastructure for staff to develop this programme and they had been invited to present their plans and work so far at a national Health and Social Care Awards ceremony.
Patients on a cancer pathway had a dedicated booking team in the booking centre. All referrals were received electronically and an email was sent to the GP to indicate it had been received. The booking team escalated concerns about appointments to service managers. Weekly cancer patient tracking list meetings provided clinical oversight of patients on cancer pathways.
The paediatric team had introduced a ‘consultant of the week’ system whereby a designated consultant answered enquiries from local GPs about sick children in their care. This recent initiative had reduced the number of admissions because GPs had a specific point of contact and could be supported to care for the child in the community, where practical.
An entrepreneur programme was being established that focused on the reduction of ambulance handover delays.
There were good initiatives being developed and encouraged to meet people’s individual needs. The hospital’s League of Friends team had knitted comfort bands for patients, which helped them stop picking at intravenous lines. A ‘distraction box’ was also available to help provide stimulation for patients with dementia and reduce their anxiety in an unfamiliar environment. A nurse had developed a number of resources to help provide emotional support to parents who lost a child to sudden infant death syndrome.
A member of the maintenance team had given up his own time to paint a mural on the wall of the recently decorated ultrasound unit to soften the environment for young patients

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

Importantly, the trust must :

Ensure that consultant cover meets the minimum requirements of 16 hours per day, as established by the Royal College of Emergency Medicine.
Must develop play services in line with national best practice guidance.

In addition the trust should:

The surgery directorate should ensure completion of anaesthetic machine logbooks
The surgery directorate should ensure compliance with: inadvertent perioperative hypothermia, NICE guidance clinical guideline CG 65.
The surgery directorate should ensure accurate record keeping of controlled drugs in theatres.
The surgery directorate should improve the quality, content and outcomes of mortality and morbidity meetings.
The surgery directorate should ensure compliance with the guidance contained in venous thromboembolism (VTE) in adults: reducing the risk in hospital QS3.
The surgery directorate should ensure compliance with National Patient Safety Alerts regarding safer spinal and epidural needles.
The surgery directorate should ensure a consistent governance structure across the two surgical directorates.

Review all maternity policies and procedures that are outside their review date and take action to ensure all policies reflect current national and evidence-based guidance.
The hospital should discuss and record ceilings of care for patients who have a DNACPR.
The trust should have a defined regular audit programme for the end of life care service.
The trust should record evidence of discussion of an end of life care patient’s spiritual needs.
The trust should implement a formal feedback process to capture bereaved relatives views of delivery of care.
The trust should ensure that all staff received regular mandatory training for end of life care.
The trust should provide a formal referral criterion for the specialist care team for staff to follow.
The trust should define and streamline their end of life care service to ensure staff are clear of their roles and who to contact.
Develop a rapid discharge process for end of life care patients to be discharged to their preferred place of death.

Extend the Palliative care team service to provide support and advice over the full seven days. As the hospital did not currently have this provision, some patients did not have access to specialist palliative support, for care in the last days of life in all cases.
Work towards meeting the requirements of the key performance indicators of the National Care of the Dying Audit (NCDAH) 2016.
Continue to consider ways to improve staff recruitment and retention such that it meets the national recommended levels.
Play services should be developed and a play specialist employed.
The trust should ensure incidents occurring in the ED are investigated thoroughly and all staff are included in the dissemination of the outcomes.
The trust should ensure nurse to patient ratios in the ED are managed in relation to the individual needs of patients based on acuity.
The trust should ensure that RTT is met in accordance with national standards.
The trust should ensure that standard for patients receiving their first treatment within 62 days of an urgent GP referral is met.
The diagnostic department should ensure all policies and procedures are up to date.
The diagnostic imaging department should ensure they have a recent audit from their Radiation Protection Advisor.
The diagnostic imaging department should monitor their waiting times and reporting times.
The diagnostic imaging department should ensure staff attend mandatory training in line with the trusts target.
The maternity services should ensure medication locks are suitable and do not allow unauthorised patient access.
The maternity services should ensure there is a clear procedure documented for pool evacuation.
The trust should consider improving the environment in the Day Assessment Unit waiting area as flooring could be a trip hazard and the room is unwelcoming.
The maternity services should ensure a robust mechanism is in place to monitor and audit abortion HSA4 notification completion.
The maternity services should ensure resuscitation trollies are fully stocked with items that are in date, at all times.
The maternity services should ensure cleaning schedules are adhered to and audit is appropriately used to monitor this in the obstetric theatres.
The children's service should address the lack of storage space and cramped conditions on the Kipling ward.
The children's service should develop transition planning for children with long term conditions approaching adulthood.
The children's service should improve efficiency of appointment and clinic booking systems to avoid long delays in accessing paediatric review and to improve efficiency.

Professor Sir Mike Richards

Chief Inspector of Hospitals

We inspected Conquest Hospital as part of a follow up inspection of the acute hospitals provided by East Sussex Healthcare NHS Trust on 24, 25, 26 March 2015.

In a comprehensive trust wide inspection, carried out in September 2014, we identified serious shortcomings across both acute hospital sites. This inspection was focussed on the four core services that we had the most concern about to determine whether improvements had been made. We reviewed how services were being provided in the outpatients department, maternity, surgery and the accident and emergency department.

We met with the trust and representatives from the Trust Development Agency (TDA) on 23 March 2015. The trust talked to us about the draft action plan created following our September 2014 inspection. We were provided with a copy of the draft action plan on 27 March 2015 but have since received a final action plan which appeared more robust and focussed.

The trust serves a population of around 525,000 patients from across the East Sussex area. There are approximately 700 beds and almost 7,000 staff. The hospital provides a full range of DGH services to its local population although some services are only available on one site. Consultant led obstetric services, acute services for children and young people and trauma and emergency surgery are only available at the Conquest Hospital. The trust has links to larger hospitals in Brighton, Tunbridge Wells and London for some tertiary services.

We found some early improvements had been made by individual teams and departments but these were not sufficient to provide assurance that the trust was providing an acceptable level of care in the four core services we inspected. The trust had failed to effectively address the issue of staffing that failed to meet the national recommendations and this had a real impact on staff morale and wellbeing, patient choice and safety. We were told of several incidents of unacceptable behaviour by senior staff and saw several incident reports where senior staff had prioritised targets over patient and staff welfare.

We also identified serious concerns about the culture and leadership within the trust. This permeated throughout both sites with staff feeling unable to raise concerns and a perception that they were not listened to. We also saw the response to the chair of an external stakeholder group when they raised concerns; the CEO suggested that the chair should consider their position as, "They no longer had the support of East Sussex Healthcare Trust".

We saw overall that safety was inadequate, that the trust was not responsive to the needs of many of its patients, and that leadership was inadequate. We found that effectiveness and responsiveness of many areas required improvement.

We found that caring was largely good across both sites. However, the NHS Staff Survey 2014 demonstrated very low staff morale and we found high staff sickness levels at the trust.

The trust could not demonstrate compliance with the National Specification for Cleanliness in the NHS.

The trust had shared a draft action plan following the publication of the report of the September 2014 inspection but this failed to effectively address all of the issues that we said they must take action on in our previous report.

Our key findings were as follows:

We saw on-going challenges with staffing in some areas and could identify where this had impacted on patient welfare.
The quality of the medical notes remained unsatisfactory. Many clinics were running without patient health records and using temporary sets of notes. Health records were in a poor state of repair. Some incidents could not be reviewed satisfactorily because of poor record keeping.
We were unable to see evidence of clear strategies to monitor and maintain robust systems to ensure that the trust improved their waiting times and met with these targets..
Operational staff were stressed, unhappy and keen to discuss their experiences throughout our visit. We were contacted by a number of staff who felt unable to raise concerns within the organisation.
The trust board continues to say they recognise that staff engagement is an area of concern but the evidence we found suggests there is a void between the Board perception and the reality of working at the trust. At senior management and executive level the trust managers spoke entirely positively and said the majority of staff were ‘on board’, blaming just a few dissenters for the negative comments that we received.
We found the widespread disconnect between the trust board and its staff persisted. This did not appear to be acknowledged by the senior management team.
The NHS staff survey shows the trust below average for 23 of the 29 staff engagement measures and in the worst 20% for 18 of these.
We saw a culture where staff remained afraid to speak out or to share their concerns openly. We heard about detriment staff had suffered when they raised concerns about risks to patient safety.
Staff remained unconvinced of the benefit of incident reporting, and were therefore not reporting incidents or near misses to the trust. the trust was not able to benefit from any learning from these. this position had not improved.
We found that management of outpatients’ reconfiguration has led to service deterioration with long delays in the referral to treatment time in some specialities. We did, however that local managers had taken some steps that had resulted in an improved patient experience.
In surgery and OPD there was clear evidence of significant underreporting of incidents through the correct system. This related to high tolerance or thresholds in the surgical clinical unit and a management decision to prevent staff reporting OPD reception incidents through the proper channels.
We saw low staffing levels that impacted on the trusts ability to deliver efficient and effective care.
The poor quality of health records and frequent lack of availability continued to pose a risk.
Storage and operational arrangements did not ensure that people's personal information remained confidential.
The referral to treatment times in a number of specialities continued to be significantly worse than expected when compared nationally.
Short notice cancellations of outpatient clinics continued to be a problem. Large numbers of appointments were cancelled at very short notice. In some cases, people arrived for the appointment unaware it had been cancelled.

We saw one area of outstanding practice :

In maternity the telephone triage system allowed women to access information and advice without necessarily attending the unit.

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

Importantly, the trust must:

Give full consideration to whether there have been any breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Regulation 5 (3)(d) Fit and proper persons: directors
Review the tracking of records. The outpatient department were not tracking patient health records because this job had not been considered during the redesigning of the service. The location of medical records were often unknown and resulted in delays or temporary notes being used. Trusts have a responsibility to track all patients’ health records (Records Management: NHS Code of Practice Part 2, 2nd Edition, January 2009).
Comply with the Data Protection Act 1998. The outpatient department was not protecting patients’ confidential data. Patient records were left in public, accessible areas without staff present.
The trust must make sure the privacy and dignity of patients is upheld by avoiding same sex breaches in the clinical decision unit (CDU).
Ensure that there are adequate staff, including managers, consultant midwives and labour ward coordinators employed to meet the recommended minimum standards detailed in Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in Labour, Royal College of Obstetricians and Gynaecologists (RCOG), Royal College of Midwives (RCM), Royal College of Anaesthetists (RCA), Royal College of Paediatrics and Child Health (RCPCH), 2007.
Review staffing arrangements for the community midwifery service to ensure they are compliant with the Working Time Regulations (1998), which implement the European Working Time Directive into British law.
Ensure that all women in established labour receive one-to-one care from a registered midwife.

In addition the trust should:

Make sure the privacy and dignity of patients is upheld by reviewing the arrangements and facilities for patients awaiting radiological investigations.
Ensure that the room in the ED designated for the interview of patients presenting with mental health needs has a suitable design and layout to minimise the risk of avoidable harm and promote the safety of people using it.
Review the number and skill mix of nurses on duty in the ED department to reflect NICE guidelines to ensure patients’ welfare and safety are promoted and their individual needs are met.
Review the number of consultant EM doctors in the ED and how they are deployed to reflect the College of Emergency Medicine (CEM) recommendations.
Improve the uptake of mandatory training amongst staff working in Urgent Care.
Make sure there are enough competent staff working in Urgent Care to respond to a major incident.
Review the arrangements for monitoring pain experienced by patients in the ED to make sure people have effective pain relief.
Review their arrangements for assessing and recording the mental capacity of patients in the ED to demonstrate that care and treatment is delivered in patients’ best interests.
Make arrangements to ensure contracted security staff have appropriate knowledge and skills to safely work with vulnerable patients with a range of physical and mental ill health needs.
Review some areas of the environment in the ED with regard to the lack of visibility of patients in the children’s waiting area; the arrangements for supporting people’s privacy at the reception and triage bay and the suitability of the relatives’ room
Review the provision of written information to other languages and formats so that it is accessible to people with language or other communication difficulties.
Ensure fridges used for the storage of medicines are kept locked and are not accessible to people and that medicines are secured in lockable units. This is something that is required as part of Regulation 13 in relation to the management of medicines but it was considered that it would not be proportionate for that one finding to result in a judgement of a breach of the Regulation overall at the location.
Consider how it may improve the experiences of women with regard to their pain management.
Consider ways of updating policies and procedural guidance so staff have access to relevant information.
Consider how it enables staff to attend required training and supports staff to gain additional qualifications to support the service.
Consider how it can improve the checking of all technical equipment across each department.
Consider how it can improve the completion of care records, so that all risks are assessed and recorded.
Consider ways of improving the bereavement facilities.
Improve breastfeeding support to new mothers.
Consider ways of improving peoples experiences related to food, inappropriate discharge times, antenatal and parent craft provision and partner facilities.
Consider the particular needs of vulnerable groups of women and babies within their catchment and provide adequate resources to meet those needs.
Consider ways of improving the sharing of information and improving engagement with midwifery staff, so they are aware of and involved in future developments.
Provide resources to accommodate the needs of women in early labour where repeated journeys between their home and the hospital may be inadvisable.
Communicate more effectively with the local population to ensure they understand the services available and the reasons for decisions being made.

Subsequent to this inspection visit a warning notice served under Section 29a of the Health and Social Care Act 2008. This warning notice informed the trust that the Care Quality Commission had formed the view that the quality of health care provided by East Sussex Healthcare NHS Trust requires significant improvement:

On the basis of this inspection, I have recommended that the trust be placed into special measures.

Professor Sir Mike Richards

Chief Inspector of Hospitals

We inspected Conquest Hospital as part of the East Sussex Healthcare NHS Trust inspection on 10,11 and 12 September 2014. The trust was placed in band 1 in our Intelligent Monitoring latest data, and therefore recognised as a high priority for inspection (band 1 being highest and band 6 lowest).

The trust serves a population of around 525,000 patients from across the East Sussex area. There are approximately 700 beds and 7,200 staff. The hospital provides a full range of DGH services to its local population although some services are only available on one site. Consultant led obstetric services, acute services for children and young people and trauma and emergency surgery are only available at the Conquest Hospital. The trust has links to larger hospitals in Brighton, Tunbridge Wells and London for some tertiary services.

We found that services provided at the hospital were inadequate, with particular concerns about the provision of services in Maternity, Outpatients and Surgery.

We saw overall that safety was inadequate, that the trust was not responsive to the needs of many of its patients, and that leadership was inadequate. We found that effectiveness of many areas required improvement.

We found that caring was largely good across the trust. However, the NHS Staff Survey 2013 demonstrated very low staff morale and we found high staff sickness levels at the trust

Our key findings were as follows:

We saw challenges with staffing in some areas. We saw poor management of medicines in a number of areas and practices that our clinical experts deemed unsafe.
We found concerns relating to the under-reporting of clinical incidents. We found discrepancies in the approach to speciality-specific mortality and morbidity reviews. In some cases, these meetings were firmly embedded, but in others they had not taken place for at least six months. We identified concerns with medication management within the department and subsequently undertook a specialist pharmacy inspection as part our unannounced visits.
The quality of the medical notes we viewed were unsatisfactory. Many clinics were running without patient health records and using temporary sets of notes. Health records were in a poor state of repair
We were unable to see evidence of clear strategies to monitor and maintain robust systems to ensure that the trust improved their waiting times and met with these targets..
Staff had been unsettled by the changes brought about by the reconfiguration of services to single site delivery and were stressed, unhappy and keen to discuss their experiences of this change throughout our visit. Staff mostly acknowledged the reasons for the changes but felt that they had occurred with little consultation, without a good knowledge of their job roles, and without adequate support. There were examples of poor patient experiences as a result of the changes..
At Eastbourne Hospital; the maternity services are provided as a midwife led unit through the consultant led maternity unit at Conquest Hospital is Hastings. All maternity services are reported in one report which can be found in the Conquest Hospital report.

We saw several areas of outstanding practice including:

Consultant presence on critical care 7 days per week.
Good leadership in ITU
Nurse led discharge
Introduction of VitalPAC

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

Importantly, the trust must:

Develop a clear and explicit vision for their maternity services and a strategic plan to allow the vision to be achieved. The vision and plan must be created in collaboration with key stakeholders, staff and service users.
Ensure that there are adequate staff, including managers, consultant midwives and labour ward coordinators employed to meet the recommended minimum standards detailed in Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in Labour, Royal College of Obstetricians and Gynaecologists (RCOG), Royal College of Midwives (RCM), Royal College of Anaesthetists (RCA), Royal College of Paediatrics and Child Health (RCPCH), 2007.
Consider the needs of low-risk women giving birth at the Conquest Hospital and ensure that facilities and staffing are such that normal birth is actively promoted.
Review staffing arrangements for the community midwifery service to ensure they are compliant with the Working Time Regulations (1998), which implement the European Working Time Directive into British law.
Ensure that medical records and other sources of confidential personal information are managed such that the service is compliant with the requirements of the Data Protection Act 2003 and the guidance issued by professional associations and royal colleges.
Improve the way information is collected and used. The governance and incident reporting structure must be strengthened and streamlined to ensure that data is sufficiently accurate and robust to be used to inform service improvements.
Improve the security arrangements at the Conquest Hospital maternity unit.
Improve the way handovers on the labour ward are managed.
Ensure that all women in established labour receive one-to-one care from a registered midwife.
Ensure that all staff have a sound understanding of how to obtain and record that informed consent has been sought before any clinical intervention.
Take active measures to improve multidisciplinary team working at the Conquest Hospital.
Review the tracking of records. The outpatient department were not tracking patient health records because this job had not been considered during the redesigning of the service. The location of medical records were often unknown and resulted in delays or temporary notes being used. Trusts have a responsibility to track all patients’ health records (Records Management: NHS Code of Practice Part 2, 2nd Edition, January 2009).
Comply with the Data Protection Act 1998. The outpatient department was not protecting patients’ confidential data. Patient records were left in public, accessible areas without staff present.
Review resuscitation equipment in the outpatient departments, as it was not all fit for purpose.
Ensure that outpatients medicines are prescribed and dispensed in line with relevant legislation. The department had not ensured that when medicines were prescribed and dispensed, the prescription and dispensing complied with relevant legislation.
Ensure that outpatients medicines are stored at the correct temperatures. They were unable to provide assurance that this medication had been stored at the correct temperature.
Ensure that outpatients staff report incidents in accordance with trust policy and statutory requirements.
Make sure the management of medicines within the emergency department (ED), including storage and recording of temperatures, is done in accordance with national guidelines.
Make sure the privacy and dignity of patients is upheld by avoiding same sex breaches in the clinical decision unit (CDU).
Conduct a trust-wide review of venous thromboembolism (VTE) compliance as a matter of urgency.
Address our concerns regarding the emergency equipment checking.
Conduct a trust-wide review of medication compliance.
Review and improve the complaints handling process to ensure that the service learns and improves as a result.
Review occupational health and HR support mechanisms and resources in place for staff who are on long-term sick leave, or who require support, to ensure the trust can meet its duty of care to its workforce.
Conduct a trust-wide review of staffing levels to ensure that patient acuity and turnover is taken into consideration.
Address the long wait for oral and maxillofacial surgery for adults with learning disabilities.
Review medical cover on the Conquest Hospital site.
Identify and address inappropriate staff behaviour toward patients, relatives and staff.

In addition the trust should:

Improve infection prevention and control measures on the maternity unit at the Conquest Hospital.
Improve the facilities and pathway for women suffering pregnancy loss at the Conquest Hospital maternity unit.
Ensure that medicines, particularly controlled drugs, on the maternity unit at Conquest Hospital are managed in accordance with the trust policy.
Make comprehensive, written information available to women using services in relation to the choices of place of birth available to them.
Improve breastfeeding support to new mothers.
Ensure women who need to be transferred after giving birth are not separated from their babies.
Consider the particular needs of vulnerable groups of women and babies within their catchment and provide adequate resources to meet those needs.
Provide resources to accommodate the needs of women in early labour where repeated journeys between their home and the hospital may be inadvisable.
Communicate more effectively with the local population to ensure they understand the services available and the reasons for decisions being made.
Review the out-of-hours medical cover available on the site to ensure there are sufficient staff to meet the needs of all patients without undue delay during busy periods.
Look at the system for reviewing serious medical incidents and ensure that there is oversight from doctors. Staff completing the reviews should have appropriate training to ensure that full in-depth analysis is completed and clear learning streams identified.
Review how medical incidents are managed and escalated to ensure that the appropriate management staff are involved at an early stage to oversee actions and escalate and disseminate information appropriately.
Review staff compliance of fully and accurately completing documentation and feedback to teams on good and poor practice. Accurate documentation was not being consistently completed on medical wards
Should integrate executive-level staff with the workforce at a local level, allowing them to observe practice and assess the impact of changes at departmental and individual level. This will help to increase staff inclusion, confidence and empowerment.
Should have strategies in place to improve outpatient waiting times consistently in all specialities. The central booking service was not always able to give patients appointments within the NHS England and clinical commissioning groups (CCGs) regulations (2012) 18-week targets.
Ensure clear strategies are put into place to improve outpatient waiting times against the national average. The trust was falling below national averages with the two-week wait timescale for patients with urgent conditions such as cancer and heart disease.
Ensure that patients are offered follow-up appointments within the timeframe considered clinically appropriate.
Ensure that patients are managed effectively through the department; patients are sent to the correct areas of the outpatient department and are expected by staff in those areas when they arrive. Staff should be able to track patients’ journeys through the department.
Ensure that they are obtaining correct data regarding patient pathways and recording accurate data for 18-week and two-week waiting times.
Consider reviewing some areas of the environment in A&E with regard to arrangements for supporting patient privacy and the overall security of the department.
Ensure the implementation of pain assessments for patients in A&E. We saw poor use of pain measurement.
Make sure any assessment of patients’ capacity or best interest decisions are accurately recorded in patient records.
Take action to ensure that staff receive mandatory training in line with trust policy.
Ensure that patient information is available in languages other than English and in other formats so that it is accessible to people with disabilities.
Make sure staff receive an annual appraisal in line with trust policy.
Review their methods of sharing information with the population they serve to improve public engagement.
Enable there to be end of life champions on every ward and deliver regular training to develop and maintain knowledge and skills. The trust-wide training strategy did not have end of life care embedded in it, at the time of the inspection.
Consider the implementation of McKinley T34 syringe drivers across the trust with mitigation plans to support the transition from Omnifuse syringe drivers.
Ensure that discussion at the end of life steering group could include end of life incidents and cascade learning across the trust.
Regularly review the quality of the Mental Capacity Act 2005 assessments and the need for assessment to be clearly document.
Review the quality of nursing documentation to ensure it accurately reflects the care delivered with individualised care plans for end of life patients.
Collect and consider the opinions of carers of patients receiving end of life care to support a continuous cycle of improvement.
Review the support provided to the specialist palliative care team to ensure the resources enable them to achieve their ambitions for the trust. Improved leadership and administrative support is required.
Consider expansion of the specialist palliative care team to enable face-to-face working seven days per week.
Consider the introduction of an end of life electronic alert system across trust.
Improve the profile of end of life care across the trust by introducing a standing trust board agenda item on end of life care and have a designated clinician as trust-wide lead for end of life, who understands what is needed and who is empowered to implement policy.
Ensure that an integrated strategy for end of life care is put in place, as the trust is an integrated acute community trust.
Audit the effectiveness of nurse-led discharges (trust wide) and the admissions (SAU at Conquest Hospital).
Improve staff morale and seek ways of improving communication effectiveness.
Review the quality of nursing documentation to ensure it accurately reflects the care delivered.
Ensure all agency and transient staff have a full induction in clinical areas, which is formally recorded.
Review medical cover at the Conquest Hospital.
Address theatre efficiency across both sites and in all theatres.
Engage in effective listening with staff to improve efficiency.

Professor Sir Mike Richards

Chief Inspector of Hospitals

On the 7 May 2013 the East Sussex Healthcare NHS Trust (ESHT) completed a temporary reconfiguration of maternity and paediatric services. This had been undertaken as a result of an escalation in concerns regarding the overall safety of Maternity provision within the acute hospitals.

The Care Quality Commission made plans to review the newly configured service, and allowed a month for the new service arrangements to embed. Prior to our planned visit we received information from a team of consultant paediatricians working at Eastbourne District General Hospital. They expressed concerns about the new arrangements for paediatrics across the Trust. We met with the consultants on 18 June 2013 supported by a paediatric specialist. We listened to their concerns and gave these due consideration in our planned inspection of these services.

When we visited the services at the Conquest we were supported by a paediatric specialist, and a maternity specialist. We spoke with staff at all levels of the Trust to gain their views about the safety of the service. We looked at systems, and reviewed documentation. We spoke with parents, mothers and relatives of people using these services. From the feedback we received and records viewed we were satisfied that the Trust was providing a safe, effective, responsive, caring and well led maternity and paediatric service.

We met the trust Chair, Chief Executive and spoke with staff at all levels. We reviewed a range of documentary evidence. We found that systems were in place for the safe management of medication. Quality monitoring systems were embedded and effective in providing information about the operational quality of patient services across the trust.

Staff we met were welcoming and co-operative. At ward level they demonstrated awareness and commitment to the improvements around recording of patient care, and confirmed the monitoring systems in place. They told us they felt they were kept informed.

We saw that backlogs in the management of complaints and serious incidents had been addressed and processes implemented to minimise recurrence. Scrutiny through review groups and subcommittees provided assurance that emerging patterns or increased incidence in any area was discussed and investigated. Written and verbal evidence indicated the trust was proactive in identifying issues and seeking advice from external organisations or specialists to gain assurance around patient safety.

Programmes had been implemented for listening to staff and strategies for engaging with patients. We saw early analysis of patient feedback on some wards but it was unclear how this influenced service development. From discussion with staff it was clear that shared learning from safeguarding and incidents was undeveloped and discharge arrangements for patients varied between wards.

We spoke to people using the service (patients), relatives, and staff in all of the areas we visited.

Patients told us that they felt their privacy and dignity was respected, that staff ensured curtains were closed during personal care and treatment.

We were told that patients were involved in their care and treatment. One patient told us 'When I ask about my condition I get an honest answer'. Another told us 'Staff are so thoughtful and kind, you can't fault them' and another told us 'I choose to get up and dressed every day'. A visiting carer told us that staff were aware of the communication tools to use with a patient with learning disabilities.

Staff told us they had received training in privacy and dignity and in respecting choices. An occupational therapist told us that they ensure patients are covered in a dressing gown when they go for therapy.

Patients told us that staff were polite to them and that they felt safe in the hospital.

Overall most patients were very complimentary about their care and treatment throughout their hospital stay.

We visited Maternity, MacDonald, Egerton, Benson, Cookson Devas and Wellington wards. The majority of patients we spoke with told us that they felt well informed about their care and treatment and had been involved in decision making around this.

Patients said that medical and nursing staff were actively maintaining their privacy and dignity by pulling curtains and in some instances using clips to further improve privacy.

Overall patients told us that the care they had received had been good and that staff had a good understanding of their needs.

Most patients spoken with thought that the general standard of cleanliness was good.

However on MacDonald ward two patients spoken with said that they had not been appropriately supported.

The patients that were able to speak with us told us that they were satisfied with the care and treatment they received at the Conquest Hospital. Four relatives also told us they were happy with the care their relative was receiving. They stated they had been treated with courtesy and respect and that their privacy and dignity had been well-protected.

'Very good staff, always polite and so very helpful' 'Nice staff, the doctors are very polite and they keep me well informed of my test results and treatment' 'Very good, speak to me as if I mattered'

'The ward is wonderful, could not be cared for any better' 'I feel that sometimes I could be taken to the bathroom, I feel a little embarrassed using a commode in the ward'.

Some patients said that hospital staff provided advice and information to people about their health needs and the management of their condition. Two patients said 'Helpful and kind' 'Information is given, but I have to ask '.

We were told by patients that staff had asked them what they wanted to be called on their admission to hospital and that this was respected throughout their stay.

However, people also told us that their preferences were not always asked for or taken into account such as having a choice of male or female staff for personal care.

People we spoke with gave us mixed feedback about the mealtimes, food and nutrition provided during their stay in hospital.

Positive comments included that the food is much better than it used to be, and that there is a good choice. One person said, 'Always something I fancy' Other comments included, 'I enjoyed the food, I am never hungry and there is always enough to eat'.

Some of the people told us that the meals look alright but is lacking in taste, mainly due to being slightly dry. Other comments were that there is limited choice for special dietary needs and that the main meal and a hot dessert are given at the same time so the dessert has to be eaten cold. One patient told us the food 'Tasted horrible', because she was given her medication at the same time. Another said 'I don't like the food so I don't eat it'.

We spoke to people using the services and staff in each of the areas that we visited.

People who use the maternity service said they were able to decide what care and support they would have. Women told us that they know what is in the care plans, they agreed with the information in them before coming into hospital, and the staff were 'very good' and they are 'very happy with the support from the staff' who are available if they need anything.

People thought that the maternity department was generally clean and they did not have any concerns. Some comments were made that the toilets were not particularly clean at the end of the day. Users of the services stated that staff were regularly seen to wash their hands.

The people spoken with in A&E who were able to express a view of the care were very positive about the treatment they received. They felt the staff were professional and attentive. People were satisfied with the care that they received while a patient in the Accident and Emergency department. They felt that the staff were attentive and responded to their needs in a timely manner.

Two people spoken with on the wards generally felt that they were looked after well. With comments ranging from 'can't fault the staff' to 'excellent care'. There were mixed views from patients, with some stating that they were awaiting further tests and were unclear as to when they would be carried out or why, while other patients felt well informed by medical staff about their condition and treatment and also felt listened to by staff.

Patients spoken with confirmed that their personal hygiene needs were being attended to, however one patient said that his wife had commented on his unshaven appearance and he had now received two shaves in a week.

One patient stated that they were very impressed with how their spiritual needs were being met and that they had three visits from local priests.

Other patients spoken with stated that overall they found the cleanliness to be good. Comments included: 'High standard, cleaner will daily include all the loos and bathrooms', 'toilets all kept clean', 'staff are always hand washing between patients' ' the hand washing is almost excessive, but reassuring.'

One person said that staff respond to call bells quickly, others said 'not immediately but any longer than five minutes', 'it depends what staff are doing, and sometimes it can take a while'. Another person said that they try to ensure that they call well in advance of needing staff so that they can allow for response time.

Only one of nine people spoken with on the wards said that they had looked at their individual care notes. Two people said that they didn't think they were allowed to look at them. A number asked what was included in the folders. When asked if staff involved them when recording their notes everyone said no.

Conquest Hospital

All Inspections

19 October 2022

During an inspection looking at part of the service

05 November to 12 December 2019

During a routine inspection

6 March 2018

During a routine inspection

4, 5, 6 October 2016

During an inspection looking at part of the service

Professor Sir Mike Richards

24, 25 , 26 March and 10 April 2015

During an inspection looking at part of the service

Professor Sir Mike Richards

24 March 2015

During an inspection of this service

9 – 12 September 2014

During a routine inspection

24 June 2013

During a routine inspection

24, 29 January 2013

During an inspection looking at part of the service

26 April 2012

During an inspection looking at part of the service

21 September 2011

During an inspection looking at part of the service

20 May 2011

During a themed inspection looking at Dignity and Nutrition

17 February 2011

During a routine inspection