Royal Papworth Hospital NHS Foundation Trust

Papworth NHS Foundation Trust provides is the UK’s largest specialist cardiothoracic hospital and the country’s main heart and lung transplant centre. The trust treats over 23,700 inpatient and day cases and provides over 124,066 outpatient appointments each year. Services are internationally recognised and include cardiology, respiratory medicine, and cardiothoracic surgery and transplantation. Papworth Hospital is a regional centre for the diagnosis and treatment of cardiothoracic disease, and a national centre for a range of specialist services, including pulmonary endarterectomy. It is one of the first centres in Europe to offer transcatheter aortic valve implantation (TAVI). Papworth Hospital has the largest respiratory support and sleep centre in the UK.

We carried out this inspection as part of our comprehensive inspection programme.

We carried out an announced inspection of the hospital on 3 and 4 December 2014, and an unannounced inspection on 14 December. We looked at all the inpatient services, including the Progressive Care Unit, and the outpatients department.

Our key findings were:

Overall we found that the trust provided highly effective care with outcomes comparable with or above expected standards. The service was delivered by highly skilled, committed, caring staff and patients were overwhelmingly positive about the care they received at the hospital. We rated both the effective and the caring domains as outstanding.

There were elements of the well led domain that were very good particularly in relation to the comprehensive research and development programme that encouraged service development and innovation for the benefit of patients.

There was a very positive culture in the trust. Staff were very proud of the work they did and very proud of the trust. They were aware of the trust’s positive reputation and worked hard to maintain and enhance it.

However, staff were unaware of the vision for the future of the trust other than the building of a new hospital. The trust’s values of ‘Care, Valued, Excellence and Innovation’ were developed following a workshop with staff in June 2014 nevertheless the trust’s vision and values were not widely visible or understood throughout the organisation.

We also found that the trust needed to develop its strategic approach as the trust did not have a quality strategy in place. In addition, there were no strategies in place for caring for people living with dementia, or organisational development. However the Organisational Development (people) Strategy was in development at the time of our inspection

Governance and risk management systems also required improvements as risk registers were not well managed at ward, department, business unit or corporate level. A significant proportion of the risks had been on the risk registers for years. Common themes were poor risk descriptions (particularly about the cause of the risk), out-of-date risks that were some years old and uncertainty whether reviews of the controls (existing policies and practices) had occurred. This led to concern about the trusts approach to the management of risks within the organisation.

Although the trust had outstanding ratings for two key questions and good ratings for the other three, the poor governance precluded an overall rating of outstanding across the trust.

Access and flow

• The outpatients department provided 124,066 outpatient appointments during 2013/14, of which 67% were follow-up appointments. The follow-up to new patient ratio was in the highest 25% in the country.
• The referral-to-treatment time of 18 weeks for cardiology patients in the outpatients department was 98.8% which was good performance, and most other referral-to-treatment times were also meeting the national targets.
• The trust had been failing to meet national referral-to-treatment times for cardiothoracic surgery. This had been rectified at the time of our inspection.
• There were also a significant number of cancelled operations and high theatre use, and a number of patients had not had their surgery 28 days after their operation was cancelled. This was due to a number of reasons, including late referrals to the hospital from other centres that meant referral-to-treatment time targets could not be met, changes in patients’ conditions that meant they were unfit for surgery and capacity issues because of increased demand for some services.
• There were also concerns that the surgical department had no designated emergency theatre, which meant that elective operations were sometimes cancelled or emergency cases waited until a theatre was free.
• There was increasing demand for a number of services provided at the hospital, but service expansion was constrained because of the physical environment and limited building space on the site.

Cleanliness and infection prevention and control

• Patients received their care in a clean and suitably maintained environment. There was a high standard of cleanliness throughout the trust. Staff were aware of current infection prevention and control guidelines and were supported by staff training and the adequate provision of facilities and equipment to manage infection risks.
• There was a good rate of compliance with hygiene audits across the hospital.
• Some aspects of infection prevention and control were not being managed effectively, including the routing of outpatients through inpatient wards.
• The hospital infection rates for Clostridium difficile and MRSA were within an acceptable range for a hospital of this size and the number catheter-associated urinary tract infections was consistently low.
• The trust had made a positive response to a small cluster of infections that had occurred in surgery. An investigation and root cause analysis were completed and changes to practice were made to reduce infection rates.

Nutrition and hydration

• Patients had a choice of food and an ample supply of drinks during their stay. Patients with specialist needs for eating and drinking were supported by dieticians and other relevant professionals
• There was good support for patients who needed assistance with eating and drinking, who were offered appropriate and discreet support.

Incident reporting

• The trust had an average patient safety incident reporting culture. The latest National Reporting and Learning System (NRLS) data indicated that the trust had a reporting rate of 7.59 per 100 admissions, which is just slightly below the average of 7.63 for the cluster of acute specialist trusts. This reflected our inspection findings, because although staff confirmed that they knew how and what to report, we found instances where incidents had not been reported or reported in a timely way.
• The trust was slow to upload incidents to the NRLS system, with 50% of incidents submitted more than 71 days after the incident occurred. This was in the lower performance bracket for specialist trusts. However, the trust’s process was to upload the incidents to the NRLS following investigation and the requirement was for incidents to be reviewed/investigated within 28 working days. This approach means that incidents are uploaded on a monthly basis 2 months in arrears. The Trust did upload incidents for 6 out of 6 months in the reporting period.
• The trust had reported and investigated two Never Events over the last 18 months. The quality of the investigation reports for these incidents varied.
• Additional incident investigation reports reviewed also varied in quality, rigour and depth.
• The trust used a sharing lessons document to communicate learning from incidents, which had been in place since 2012. This was readily accessible on the intranet site and summarised findings and learning from serious incidents.
• However, some opportunities for learning were missed because of delays or omissions in reporting and there was limited evidence of staff sharing learning across services or directorates.

Governance risk and management and quality measurement

• Risk registers were not well managed at ward, department, business unit or corporate level. A significant proportion of the risks had been on the risk registers for years, some from as early as 2005. For example, in Cardiology 11 out of 17 risks and in Estates 12 out of 14 risks dated from before 2013, and in Finance all five risks dated from before 2011, with two from 2005. One risk identified in Cardiology had a risk rating of ‘20’ (High Risk); this had been on the risk register for almost six years without a reduction in rating. We reviewed risk registers for a number of service areas. Common themes were poor risk descriptions (particularly about the cause of the risk), out-of-date risks that were some years old and uncertainty whether reviews of the controls (existing policies and practices) had occurred. The review dates for all risks had passed, but were within 2014, so it was not clear whether this was the last date that a review of the risk should have or did take place. Some staff confirmed that they were not confident in undertaking risk assessments but were aware that a number of risks had been escalated and remained on the risk register with no actions taken.
• In addition we found that the executive team provided the board with Board Assurance Framework document that contained risks set against the ‘risk appetite’ (within agreed tolerance levels) agreed by the board, as opposed to receiving current and target risk ratings. The Board Assurance Framework comprised 19 risks; nine were within the ‘risk appetite’ set by the Board. There had been limited change in the risks included on the Board Assurance Framework, with only one risk having changed in risk score, where the risk score had increased.

Medicines management

• The trust used a comprehensive prescription and medication administration record chart for patients that enabled the safe administration of medicines. It included a separate section for antibiotic medication. Medicines reconciliation by a pharmacist was recorded in the medicines management section. The trust took part in the NHS Medication Safety Thermometer to compare key indicators with other trusts where the trust identified shortfalls action plans were developed to secure improvement.
• Medication errors are the highest error group in the trust. Missed doses are counted as an incident, which is considered good practice. Prescribing errors and medication errors are both audited and both show an upwards trend. However, harm rates are well below the national average and indicated good reporting in this area. Action plans were in place and completion timescales identified and monitored. Lessons learnt were shared through the trust’s intranet page, junior doctors’ newsletter, pharmacy fact sheets and the sisters’ network. Plans to set up medication safety champions were in place, with the first meeting scheduled for December 2014.

Safeguarding

• Safeguarding policies and procedures were available on the trust’s intranet for both vulnerable adults and children. Safeguarding was supported by staff training. All relevant staff had received safeguarding training.
• Staff were confident and competent in reporting and escalating issues of abuse and neglect.

Nurse staffing

• Care and treatment were delivered by committed and caring nursing staff who worked well together for the benefit of patients. Nurse staffing levels were calculated using a recognised dependency tool and there were sufficient numbers of skilled and suitably qualified nurses to meet the needs of patients.
• However, we noted that in the Progressive Care Unit, where acuity of patients varied, there were no ongoing acuity assessments of patient needs. We raised this with the trust following our unannounced inspection; the trust took immediate action and introduced regular reviews of patient acuity and nurse staffing levels in this area.
• Any nursing vacancies or absences were covered by overtime or bank workers. There was limited use of agency workers, but when this was unavoidable there were systems in place to provide agency nurses with an induction and make sure that they had the required skills and qualifications to provide good care to patients.
• The trust was aware of its high nurse staffing turnover and as a result there was an ongoing recruitment campaign and a number of initiatives aimed at retaining staff. These included a comprehensive induction programme, a band 5/6 development programme and active support to achieve postgraduate qualifications. Nurses were positive about the initiatives and felt valued as a result.

Medical staffing

• Care and treatment were delivered by highly skilled and committed medical staff.
• There were excellent examples of senior medical staff supporting development and innovation in cardiothoracic services nationally and internationally.
• There was a good consultant presence throughout the wards, providing care to patients seven days a week.
• A ‘consultant of the week’ system had recently been initiated in medicine and was working well. A comprehensive handover took place from one consultant to another. Patients received high-quality care and treatment and were exceptionally complimentary about the medical staff in the trust.
• Junior medical staff felt well supported in their roles by senior medical staff and did not feel their workload was excessive. Findings from the General Medical Council Survey 2014 supported this.
• In terms of the consultant/patient ratio, with up to 33 patients on the unit and one or two consultant intensivists on duty, this falls below the best current evidence ratios as set out in the Intensive Care Society standards. However, the intensivists were supported by registrars and the consultants from the parent teams such as the transplant and cardiothoracic teams.
• From February 2015, following the anticipated addition of another consultant intensivist, this will mean that all Intensive Care Society standards for patient ratios, out of hours and training will be met with two consultant intensivist-led teams on the CCA.A review of the thoracic service commissioned in May 2014 highlighted that there was poor junior surgical support for the thoracic service and the emergency on-call rota was unsatisfactory because of the limited thoracic experience of some staff on the rota. These matters were being addressed by the trust through an action plan developed in response to the review findings.

Outcomes and evidence-based care

• Patients received care and treatment that was evidence-based and in accordance with national guidance. Clinical outcomes were comparable with or better than, the national average. Mortality rates were comparable with, or better than, other trusts nationally.
• Multidisciplinary team working was well established and used effectively to manage patients’ care and treatment needs.
• Staff at the hospital participated in an extensive programme of local, national and internationally recognised research.

Mandatory training

• The data provided by the trust showed that mandatory training levels were very good and that overall compliance with mandatory training was 91%.

Environment and capacity

• The hospital consisted of multiple buildings spread across the site. However, space was limited and the expansion of services to cope with increased demand was hampered by the site’s limitations.
• The trust was working hard to maximise its physical resources. For example, it had started to provide outpatients clinics at evenings and weekends so it could flexibly meet patient demand. However, the trust felt that the only real solution was to relocate the services in a new purpose-built hospital. At the time of our inspection the trust was waiting for confirmation that the new building project would go ahead.

We saw several areas of outstanding practice including:

• The surgical division’s effectiveness and patient outcomes were outstanding and were among the best nationally and internationally.
• The Critical Care Area had recently developed guidelines for the prevention, recognition and management of delirium. This was a multidisciplinary piece of work led by the unit’s matrons and also included members of the ALERT team and a consultant intensivist. The guidelines were about to be launched and plans were in place for the work to be shared through conference presentations.
• The hospital had direct access to electronic information held by community services, including GPs. This meant that hospital staff could access up-to-date information about patients, such as details of their current medicine.

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

Importantly, the hospital must:

• Stop the practice of routinely preparing one medicine (glyceryl trinitrate) in advance of its immediate use in the catherisation laboratory because this practice is contravenes Nursing and Midwifery Council’s standards.
• Ensure that incidents are reported in a timely manner and that learning from incidents takes place.
• Ensure that all fire exits are clear.
• Have an effective system in place to ensure that drugs stored in resuscitation trolleys are in date.
• Address the breach of single-sex accommodation on Duchess ward.
• Improve the way risk is managed and reported.
• Develop and implement a strategy for patients with a diagnosis of dementia.

In addition the trust should:

• Develop and implement a quality strategy.
• Develop and implement an organisational development strategy.
• Ensure the organisation’s vision and values are clearly articulated, shared and understood by staff.
• Strengthen its approach to incident reporting and investigations.
• Ensure learning from incidents is shared across the organisation.

Professor Sir Mike Richards

​Chief Inspector of Hospitals