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Milton Keynes University Hospital NHS Foundation Trust

This is an organisation that runs the health and social care services we inspect

Overall: Good read more about inspection ratings

All Inspections

02 Apr to 09 May 2019

During a routine inspection

Our rating of the trust stayed the same. We took into account the current ratings of services not inspected this time. We rated it as good because:

  • We rated effective, caring, responsive and well- led as good and safe as requires improvement.
  • We rated seven of the trust services as good and one, which was surgery as requires improvement overall.
  • We rated well led for the trust as good overall.
  • During this inspection, we did not inspect critical care, outpatients diagnostic imaging, services for children and young people or end of life care. The ratings we published following the previous inspections are part of the overall rating awarded to the trust this time

12, 13 and 17 July 2016

During an inspection looking at part of the service

Milton Keynes University Hospital NHS Foundation Trust consists of one medium-sized district general hospital. The trust provides a full range of hospital services including an emergency department, critical care, general medicine including elderly care, general surgery, paediatrics and maternity care. In total, the trust has 517 hospital beds. In addition to providing general acute services, Milton Keynes Hospital increasingly provides more specialist services, including cancer care, cardiology and oral surgery.

We inspected Milton Keynes Hospital NHS Foundation Trust as part of our comprehensive inspection programme in October 2014. Overall, we rated this trust as “requires improvement and noted some outstanding practice and innovation. However, improvements were needed to ensure that services were safe, effective, and responsive to people’s needs.

We carried out a focused, unannounced inspection to the trust on 12, 13 and 17 July 2016, to check how improvements had been made in the urgent and emergency care, medical care and end of life care core services. We also inspected the maternity and gynaecology service.

Overall, we inspected all five key questions for the urgent and emergency care and medical care core services and found that improvements had been made so that both core services were now rated as good overall.

For the maternity and gynaecology service, at the last inspection, all five key questions were rated as good. At this inspection, we rated safety and well-led as good.

We found that significant improvements had been made in the end of life care service and that the key question of safe was now rated as good.

Applying our aggregation principles to the ratings from the last inspection and this inspection, overall, the trust’s ratings have significantly improved to be good overall. This was because four key questions, namely effective, caring, responsive and well-led, were rated as good, with safe being requiring improvement.

Our key findings were as follows:

  • All staff were passionate about providing high quality patient care.
  • Patients we spoke to described staff as caring and professional. Patients told us they were informed of their treatment and care plans.
  • The emergency department was meeting the 95% four hour to discharge, or admission target, with a clear escalation processes to allow proactive plans to be put in place to assist patient flow. For July 2016, the department was performing at 96%.
  • The emergency department leadership team had significantly improved the department’s performance in meeting the four hour target to improve safety in seeing and assessing patients. The department leaders had implemented a range of systems and processes to drive improvements throughout the service.
  • The Hospital Standardised Mortality ratio (HSMR) was significantly better the expected rate and generally outcomes for patients were positive.
  • Whilst bed occupancy was very high, at 97%, above the threshold of 90%, patient flow was generally effective in the service.
  • The service performed well for referral to treatment times; scoring 97% across the medical specialities.
  • Improvements had been made in the completion and review of patients’ ‘do not attempt cardio pulmonary resuscitation” forms.
  • The trust had established a maternity improvement board to review incidents and risks and to drive improvements in the service. Information was used to develop the service and continually improve.
  • There was a lower rate than the national average of neonatal deaths. The maternity improvement board was monitoring this to make further improvements in the service.
  • The culture within the nursing and midwifery teams was caring, supportive and friendly.
  • Safety concerns and risks were monitored regularly in the maternity service and plans were in place to address areas of concern. Changes in practice and training had been put in place following lessons learned from incidents.
  • Staff knew how to report incidents appropriately, and incidents were investigated, shared, and lessons learned.
  • Staff understood their responsibilities and were aware of safeguarding policies and procedures.
  • There were generally effective systems in place regarding the handling of medicines.
  • Equipment was generally well maintained and fit for purpose.
  • Staffing levels were appropriate and met patients’ needs at the time of inspection.
  • Patients’ individual care records were written and managed in a way that kept people safe
  • Standards of cleanliness and hygiene were generally well maintained. Reliable systems were in place to prevent and protect people from a healthcare associated infection.
  • Mandatory training generally met or was near to meeting trust targets.
  • Appropriate systems were in place to respond to medical emergencies. Appropriate systems and pathways were in place to recognise and respond appropriately to deteriorating patients.
  • Patients’ needs were assessed and their care and treatment was delivered following local and national guidance for best practice.
  • Staff morale was positive and staff spoke highly of the support from their managers.
  • Local ward leadership was effective and ward leaders were visible and respected.

We saw several areas of outstanding practice including:

  • The medical care service had a proactive elderly care team that assessed all patients aged over 75 years old. This team planned for their discharge and made arrangements with the local authority for any ongoing care needs.
  • The medical care service ran a ‘dementia café’ to provide emotional support to patients living with dementia and their relatives.
  • Ward 2 had piloted a dedicated bereavement box that contained appropriate equipment, soft lighting, and bed furnishings to provide a ‘homely’ environment for those patients requiring end of life care.

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

  • The emergency department did not fully comply with guidance relating to both paediatric and mental health facilities. The paediatric emergency department had a door that was propped open, allowing access by all staff and patients presenting potential security risks The ED did not a have dedicated mental health assessment room that had had a robust risk assessment, allowing equipment in the room to be used as missiles. The trust took immediate actions to address this during the inspection to make these areas safe.
  • Initial clinical assessments were not always carried out in a timely way in the paediatric area, and escalation for medical review and assessment was inconsistent. This was escalated to the trust who took immediate actions during the inspection to address this. This was followed up on the third day of inspection and all children had been clinically assessed within the 15-minute period. The trust also ensured this was actively monitored on an ongoing basis.
  • There were inconsistent checks of resuscitation equipment throughout the department, not in line with trust policy. The trust took urgent action to address this during the inspection and to monitor this on an ongoing basis.
  • Staff, patients and visitors did not observe appropriate hand washing protocols when entering/leaving the department or when moving between clinical areas. The trust took action to address this and to monitor on an ongoing basis.
  • Some patients’ privacy was not respected when booking in at the reception desk in the emergency department when the department was busy.
  • The non-invasive ventilation policy was out of date and had not been reviewed. New guidance relating to this had been released in March 2016, which meant there was a risk that staff were not following current guidelines. The service was aware that it was out of date and was planning to review this; however, there was no time scale for this.
  • The medical care service did not have a specific policy for dealing with outlying patients, and therefore, there was no formal procedure to follow in these instances.
  • External, regional health service planning had affected the maternity service’s development plans.
  • In the maternity service, some examples were shared with inspectors of poor communication, inappropriate behaviours and lack of teamwork at consultant level within the service. From discussion with senior managers, it was clear that some issues had been recognised and active steps were being taken to optimise communication and team working. Such behaviours were not observed during the inspection.
  • Not all medical staff had the required level of safeguarding children’s training.
  • There was poor compliance with assessing the risk of venous thromboembolism (VTE) and the maternity service had actions plans to place to address this concern.

Importantly, the trust should:

  • Review and monitor the access and security of both the adult and paediatric emergency departments.
  • Monitor the facilities available for respecting the privacy and confidentiality of patients and relatives during the booking in process in the adult and paediatric emergency departments.
  • Monitor the initial clinical assessment times within the paediatric emergency department.
  • Monitor that recommended checks are carried out on all resuscitation equipment and documented the adult and paediatric emergency departments.
  • Review and monitor the mental health assessment room to ensure it is fit for purpose in the adult emergency department.
  • Monitor the effectiveness of staff, patient and relatives’ adherence to infection control procedures within the adult and paediatric emergency departments.
  • Monitor staff compliance with mandatory training requirement to meet the 90% trust target in the adult and paediatric emergency departments.
  • Ensure that all resuscitation and emergency trolleys are fit for purpose and robust audits are completed.
  • Ensure that agency staff have appropriate induction with evidence of completion.
  • Review the isolation facilities available on Ward 17 for patients with infections.
  • Review the storage of hazardous chemicals and needles to ensure that no unauthorised people could have access.
  • Review the non-invasive ventilation policy, incorporating the new guidance available.
  • Review the consistency of consultant cover out of hours and at weekends across the medical wards.
  • Review the arrangements for timely discharge of patients from the AMU.
  • Review the procedures for the management of outlying patients.
  • Review the process for recording the number of bed moves for patients, including out of hours and at weekends.
  • Review the specific arrangements for caring for patients with autism.
  • Review the completion of assessments for venous thromboembolism (VTE) to ensure patients’ safety needs are met.
  • Review arrangements for monitoring the cleaning of equipment in the maternity service.
  • Review the provision of pain relief provided to women in labour to ensure patients’ needs are met.
  • Review the arrangements for post-operative recovery to ensure mothers and babies can be cared for together, unless in emergencies.
  • Monitor the safeguarding children’s training provision for medical staff in the maternity service.

Professor Sir Mike Richards

Chief Inspector of Hospitals

22-23 October 2014

During a routine inspection

Milton Keynes Hospital NHS Foundation Trust consists of one medium-sized district general hospital. The trust provides a full range of hospital services including accident and emergency, critical care, general medicine including elderly care, general surgery, paediatrics and maternity care. In total the trust has 508 hospital beds.

The trust serves a population of 252,000 living in Milton Keynes and the surrounding areas. Milton Keynes is an urban area with a deprivation score of 192, out of 326 local authorities (with 1 being the most deprived). Life expectancy for men is worse than the England average, but for women is about the same as the England average.

Monitor is the independent regulator of foundation trusts in England. It issues licences to operate. In November 2014, Monitor issued enforcement undertakings on Milton Keynes Hospital NHS Foundation Trust because it was in breach of its licence. Breaches were in three areas: A&E waiting times, financial breaches (financial deficit) and governance (the failure to deliver the clinical risk management plan). The trust was taking steps to address these enforcement undertakings.

We inspected Milton Keynes Hospital NHS Foundation Trust as part of our comprehensive inspection programme. We carried out an announced inspection of Milton Keynes Hospital between 22 and 23 October 2014. In addition, an unannounced inspection was carried out between 5pm and midnight on 2 November 2014. The purpose of the unannounced inspection was to look at the accident and emergency (A&E) department and the general management of medical patients out of hours.

Overall, we rated this trust as “requires improvement," and noted some outstanding practice and innovation. However, improvements were needed to ensure that services were safe and responsive to people’s needs. Our key findings were as follows:

  • Staff were caring and compassionate and generally treated patients with dignity and respect.
  • The hospital was generally clean and well maintained. Infection rates were in line with England averages. We saw that staff washed their hands between patients.
  • The trust had consistently not met the target for treating 95% of patients attending accident and emergency (A&E) within four hours. Plans were in place to address performance, and progress was being made. The hospital was under significant pressure for beds, and demand was exceeding the capacity.
  • There were staffing vacancies in some areas, although the nursing and medical numbers had recently increased. We found some examples where staffing levels were not in accordance with the required levels, but escalation procedures were in place and risk assessments were being carried out. Patients told us that staff, particularly nurses, were very busy. We found some staff felt under pressure and were concerned that they were not able to deliver the care they wanted to.
  • There were medical staff vacancies. Recruitment was underway and the trust reported that it was finding it easier to attract the best medical staff to the hospital because they were opening a new medical school. 
  • There were no open mortality outliers at the trust at the time of our inspection. Outcomes for patients were generally good and the trust was providing effective services.
  • We saw that patients were given assistance to eat and drink, although fluid and food intake charts were not always completed. The catering department worked with dieticians and ward nurses to provide menu options for patients who required a different diet to that on offer.

We saw several areas of outstanding practice including:

  • Sensory walk rounds had taken place in the wards and departments and had led to improvements for people who had visual impairments.
  • The Cancer Patient Partnership group was providing the trust with an outstanding way of engaging with patients and the public. There was good engagement between staff and the members of this group which had led to improvements in patient care.
  • The care delivered by staff working in bereavement teams was good, this included the care provided to women and their partners after a bereavement of a baby. The bereavement specialist midwife had recently won a national award for her work in the trust’s maternity service.
  • Leadership within surgery was "outstanding." There was a shared purpose, excellent relationships were in place and there were high levels of staff satisfaction.  Staff were very committed to working together in order to improve quality for patients.
  • Consultant medical staff were extremely engaged with the leaders in the trust and were very positive about the future for Milton Keynes Hospital.

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

The trust should:

  • The trust should ensure that patients in the waiting area in the medical assessment unit (Ward 1) have a means of calling for urgent help if required.
  • The trust should ensure that cytotoxic waste is always stored securely.
  • The trust should ensure that full and accurate records are maintained in relation to the care and treatment provided to each patient. This should include accurate recording of venous thromboembolism risk assessments for all patients, dementia risk assessments for patients aged 75 years or over, and records of food and fluids for patients assessed at risk of inadequate nutrition and dehydration.
  • The trust should ensure that there are suitable arrangements in place for all staff to receive appropriate training and appraisal.
  • The trust should ensure that patients who need inpatient care and treatment are transferred from the medical assessment unit to an appropriate ward within 72 hours.
  • The trust should ensure pre-operative safety checks are carried out in accordance with WHO for all types of surgery, including dental extractions.
  • The trust should ensure patients' privacy and dignity is maintained with the A&E department.
  • The trust should ensure the completion of DNACPR documentation is consistent across the hospital.
  • The maternity and gynaecology governance team should ensure appropriate and timely monitoring, updating and checking for the completion of action plans that had resulted from serious incident investigations or root cause analysis to ensure lessons were learnt.
  • The trust should consult with the trust’s health and safety and fire teams to establish operational protocols for partners who remain on Ward 9 overnight.

In addition the trust should consider the following areas:

  • The trust should consider working with their commissioners to ensure the service provided by the Child and Adolescent Mental Health team (CAMH’s) is consistently providing a responsive service.
  • The trust should consider reviewing the process for the nursing handover in the A&E department.
  • The trust should consider increasing the amount of information that is available for patients in languages other than English.
  • The trust should consider how they can provide better facilities for relatives who need to stay at the hospital because their relative is at the end of life. This should include a suitable space for families and or patients to talk with staff in private on ward 22.
  • The trust should consider providing protected time for departmental leaders working in A&E to have time to reflect and plan their service.
  • The trust should consider ways of improving communications between staff and managers within the A&E department and how this would improve staff morale.
  • The trust should consider reviewing the allocation of pharmacy support for the maternity service to provide medicines management and audit support.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Use of resources

These reports look at how NHS hospital trusts use resources, and give recommendations for improvement where needed. They are based on assessments carried out by NHS Improvement, alongside scheduled inspections led by CQC. We’re currently piloting how we work together to confirm the findings of these assessments and present the reports and ratings alongside our other inspection information. The Use of Resources reports include a ‘shadow’ (indicative) rating for the trust’s use of resources.

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up. Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.