The Royal Wolverhampton NHS Trust

Please note a typographical error has been corrected in the summary of Safe in this report. (October 2016)

We undertook this inspection 02 to 05 June 2015. It was an announced comprehensive inspection. This trust had been inspected in the first wave of the comprehensive programme November 2013.

Our rationale for undertaking this inspection was to rate the trust because the initial inspections did not receive a rating due to being in the early wave one pilot programme. In addition to this the trust had taken over some services from the dissolved Mid Staffordshire NHS Trust, which included Cannock Chase Hospital.

The trust had previously stated its intention to become a Foundation trust, but had had to postpone the application a number of times; allowing them to address current matters such as the integration of new services appropriately.

We recognise that we saw this hospital, and the trust is a state of change. Integrating services between New Cross Hospital and Cannock Chase Hospital. We also noted some significant building work on the hospital site, including a new Urgent and Emergency Care unit.

We inspected all core services on the New Cross site; this included Urgent and Emergency Care; Medical Care, Surgical Care, Critical care, Maternity Services, Children’s Services, End of Life care, Outpatients and Diagnostic Imaging. At the Cannock site we inspected Emergency Care; Medical Care, Surgical Care, End of Life care, Outpatients and Diagnostic Imaging. We also inspected Community services of Inpatients, Adults, Children and Young People and End of life care. Within caring we rated Adults outstanding with Children and Young People achieving outstanding for both caring and well led.

Overall we rated the trust as Requires Improvement. We rated both the New Cross and Cannock Chase hospital sites as requires improvement. We found that for safe and well led at both sites required improvement. Within the New Cross site of the eight core services we rated five services as requires improvement. We were concerned that within medical care the safe domain was rated as inadequate. The well led domain at the New Cross site rated three of the eight domains as requires improvement. Effective, caring and responsive domains for the site were rated as good.

At Cannock Chase Hospital for the safe domain two of the five core services required improvement. This was the same for the well led domain. Effective, caring and responsive domains for the site were rated as good.

The community services were rated as good overall with children and young people achieving outstanding overall. We rated adult and children and young people services  caring as outstanding and well led for children and young people services  was outstanding too.

Our key findings were as follows:

• We saw good compliance with hand hygiene and with the trusts ‘bare below the elbows’ policy. We saw that staff used hand gel and personal protective equipment appropriately. Cleaning schedules were maintained by cleaning staff.

• There were mainly sufficient medical staff to care for patients. Children’s services and radiology had vacancies and the trust were aware of these.
• We saw that the trust was meeting cancer access targets and the 18 week referral to treatment times in outpatients and in many of its surgical specialities.
  • Care was consistently good throughout the service with the exception of medical care. We saw that patients we recommend friends and family to use the service. We received good feedback from patients and visitors about the care they had receive in the hospital.
• The integration process was in progress and we saw where continued work was required. For instance in Surgery there needed to be a process for identifying the best practice and incorporating that into the trust as a whole. Within medicine we saw that the staff felt isolated from the New Cross Site. We also noted that in MIU they did not fully understand how they fitted into the vision of the trust with regard to the Emergency service strategy.
  • Nurse staffing issues was starting to have a negative effect on staff morale.
  • Within medical care the staffing was having a negative impact on patient safety and care.
• We saw sufficient equipment across the trust to meet the needs of patients, although in medical care services there was a concern about sufficient monitoring equipment.

We saw several areas of outstanding practice including:

• The hospitals SimWard was being utilised to support staff competencies. Staff told us they were in the process of expanding the service externally to provide education and learning to other authorities.
• The use of the software system ‘SafeHands’ delivered many benefits to the trust. It helped to support the infection control process and aided access and flow through the trust.

• In surgical services, we saw that the trust recently instituted “In Charge” initiative was welcomed by patients and relatives. This was a badge worn by the person responsible for that shift on the ward.

• The “panel meeting” concept where senior trust staff provided high challenge and high support to wards managers after investigation of incidents. This meeting enabled staff to take the learning from such events on board and ensure systems were put in pace to prevent reoccurrence.
  • Swan Project aimed to comfort patients and relatives, part of which enabled bereaved relatives to have keepsakes given such as locks of hair, handprints and photographs.
  • The community demonstrated that care in adult services was outstanding, in particular the services of sexual health.

However, there were also areas of poor practice where the trust needs to make improvements, these are at the end of the report in the Must and Should section.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Overall rating for this core service Good

Overall we judged community health services for adults were good.

Incidents were reported across teams, learning was identified and shared at regular meetings. The incident reporting and safeguarding policies were understood by staff and regularly used. Sufficient equipment was available and was used safely. The service had infection prevention and control policies and staff were seen to observe good practice. The service had a lone working policy in place and staff were aware of and used procedures to reduce risks when working alone. The service regularly undertook a range of audits to improve performance and support safety.

Community services had carried out a number of recent patient satisfaction surveys, with results showing a positive overall satisfaction rating of 90%. Several examples of new and emerging innovative practice were observed.

Staff and managers understood their roles and responsibilities in the delivery of evidence-based care.

A recognised assessment tool was used to identify deteriorating patients and nutrition and hydration assessments were completed. Staff appeared very competent in their contact with and treatment of patients. Multi-disciplinary working within the trust and joint arrangements with external organisations worked well. Community nursing teams worked closely with GP practices, nursing homes and with social services.

Patients and their relatives were treated with dignity, respect and compassion. Staff respected confidentiality in discussions with patients and their relatives and in their management of written records and other communications. Staff demonstrated good communication skills and were aware of the emotional aspects of care. Advice about self- care was provided when appropriate and we found some outstanding practice in this respect. Patients we spoke with were very positive about the care and treatment they received and about the members of staff with whom they had had contact.

Action to be undertaken following the investigation of a complaint was identified, the action proposed was discussed with the patient and the completion of actions was monitored. Staff could describe how services had changed as a result of action taken.

The service responded to identified risks and maintained a risk register. The service managed foreseeable risks and planned for changes in demand due to seasonal fluctuations and severe weather. The service had contingency plans in place to respond to major incidents.

Staffing levels were sufficient in most areas. In some community locations staffing levels including cover arrangements required review to ensure adequate staffing arrangements for community nursing teams so that patients were not placed at risk.

Patients could access community health services promptly when they needed to and services were provided with ease of access for patients in mind.

Completion of mandatory training stood at over 95% overall for community services for adults staff.

Staff felt there was clear leadership at executive level and the executive team were approachable. Regular open meetings were held for staff to meet with trust executives and these were well attended. Local leadership was effective and staff said their direct line managers were supportive and encouraging. Managers and staff told us they felt there was a clear vision for the community services and a strategy of improvement and development of service delivery.

Before our inspection we held two listening events to allow members of the public to tell us about their experiences of using this service. During our inspection we spoke to 24 patients, eight patients’ relatives, 76 nurses, 12 healthcare assistants, three student nurses, 24 therapists, two doctors, two pharmacists and three ancillary staff. We also looked at 28 sets of patient records.

We found that services were safe, effective, responsive, caring and well led. Achieving a overall rating of outstanding. The staff were enthusiastic, well supervised, compassionate and competent in their roles. During the inspection we met with managers, staff, children and parents in a range of community settings. We observed care being delivered in schools, outpatient clinics and in the patient’s own home. Staff from Wolverhampton Community NHS worked with other professionals and external organisations such as Child Adolescent Mental Health Service (CAMHS) and social services. There was clear evidence that the services for children and young people were delivered in line with best practice guidance and local agreement. The staff we spoke with told us that they felt they were valued members of a professional team; they told us the patient care was first and foremost of all they did and they aspired to be the best, this reflected the trusts vision and values.

We saw robust safeguarding procedures in place supported by a flow chart. An MDT approach to safeguarding alerts was seen. Staff had received safeguarding training.

There was a positive reporting culture with evidence of learning from incidents and complaints which improved the quality and safety of services. All staff had completed mandatory training which was recorded as 90% or above; in line with the trust’s target. Clinical staff had also completed specific child related training relevant to their role. From parents we heard of excellent communication between the services dealing with children and young people. We observed staff supporting children and young people in a compassionate manner ensuring they listened to them and cared for them in a respectful way; which was again confirmed by parents, young people and children who told us they felt the staff were kind, friendly, always professional and very supportive.

Environmental observations evidenced a consistently high level of cleanliness across the sites we visited. Infection control audits and cleaning schedules demonstrated that infection control practices were in place and effective. The trust supported all staff to ensure that their mandatory training was completed in a timely way and that individual training needs were addressed. Staff received regular supervision and annual appraisals; they praised the management for the level of support they were offered. We saw that during staff meetings the lone working policy had been discussed to remind staff of the risks related to their work.

The service received a low level of complaints; people we spoke with during the inspection were very complimentary about the staff and the quality of the service they received. Staff told us that early resolution of complaints avoided formal complaints being received.

The service had amalgamated with the acute service to promote a seam-free service. We heard how staff had dealt with the changes and restructuring in a positive way. We saw that the leadership of all the services was robust and senior managers were well respected; staff told us they felt fully engaged with the management and were proud to follow excellent role models.

We spoke with over 150 people during the inspection including school nurses, therapists, health visitors, family nurse partnership, physiotherapists, consultant paediatricians and administration staff. We spoke with parents/carers and young people. We spoke with young people who used the services and their parents. We observed how children and young people were being cared for. We looked at and reviewed twelve care and treatment records.

The Royal Wolverhampton NHS Trust provided community in-patient services at West Park Hospital which offered 88 beds across four wards at the time of our inspection.

The hospital consisted of four wards. The Neuro Rehabilitation ward provided 10 specialists beds for patients living with or recovering from neurological conditions such as stroke, Parkinson’s and multiple sclerosis. Ward One was a mixed sex stroke ward, ward Two provided beds for mainly elderly, frail, male patients and ward Three mainly provided beds for elderly, frail, female patients.

Security and fire procedures was a concern of staff and senior managers and was present on the West Park Hospital’s risk register for over 12 months.

The knowledge of duty of candour and safeguarding awareness was imbedded across all four wards. We saw all wards were experiencing long-term nursing vacancies which were proving difficult to fill. Despite this, outcomes for patients and patient satisfaction was high.

Policies and procedures had been developed in line with national guidance and there was an excellent stroke care pathways in place for patients.

Delayed transfer of care meant 20 out of 88 patients were ready for discharge but remained at West Park Hospital due to external social service delays.

Patients told us they felt well looked after by doctors, nurses and therapists and staff communicated well with patients and their relatives and supported them to be as independent as possible. Patients felt informed about their day to day care and discharge arrangements.

The therapy care provided across all wards was very good particularly with patients at the Neuro Rehabilitation ward.

The majority of community inpatient staff had faith in their local leaders, senior managers and executive team to lead the trust and shared the vision of the future direction. Ward staff felt able to raise issues with managers if required and felt well supported by their line managers and were proud of the service they worked in.

Good l

Overall we judged ‘End of Life care that people received as good.

Strategies had been developed for improving the end of life care that people received and teams worked together to ensure people were cared for in their preferred place of care.

The trust had introduced a new approach to providing care for people in their last days of life. This was being implemented across hospital and community nursing services (CNS) and aimed to integrate care at the end of life across the whole service. The new approach replaced the Liverpool care pathway following the 2013 review entitled ‘More care less pathway’. Providers were required to replace the Liverpool care pathway by July 2014. The trust were rolling out the new approach by training up to 50 staff a month and identifying staff who could act as champions who would support implementation.

People’s needs were anticipated and care plans were put in place to assess and meet their needs. Effective pathways had been developed for referrals and discharging people who wished to be cared for at home. The pathway for discharging people home quickly was designed to ensure community nursing staff were able to meet the person’s needs before they were discharged. For example, there were processes in place to ensure the person had the medicines and equipment they needed.

The care provided was evidence based and clinical guidelines had been put in place which had been developed by groups of expert clinicians. These ensured patients received high quality, effective care. The professional nurse lead for palliative care was responsible for ensuring hospital and community services followed national policies and guidelines.. Records were fully available to the Multi-Disciplinary Team(MDT) involved in care. Patients could access qualified staff at night and a night sitting service could be provided.

Community nursing service staff (CNS) spoke passionately about caring for people at the end of life and showed compassion for the person and their family. There were processes in place to enable the CNS staff to assess and monitor the person’s emotional needs as well as their physical needs. There was a strong culture of reporting and learning from incidents. The service responded to identified risks and maintained a risk register. The service also anticipated risks for example the cover required in the event of severe weather.

The service reviewed CNS staff caseloads to ensure the service had sufficient capacity to care for people at the end of life. Team leaders discussed workload and were able to provide cover within teams and cover for each other by staff working extra shifts.

Patients spoke positively about being able to contact the service when they needed to. They appreciated having one number to call and being able to speak with staff who were helpful and polite. Some patients would have preferred an approximate time in the appointment day.

CNS staff were released to attend role specific and mandatory training.

CNS staff spoke highly about their managers and said they felt well supported. Community staff who cared for people at the end of life were supported to cope with the emotional challenges when a patient had died. They also felt well supported by the specialist palliative care team based at the hospice.

Managers and staff told us there was a clear commitment to service improvement and innovation.

We spoke with a total of 26 patients in the community, six relatives, 17 community nurses, four healthcare assistants and two palliative care consultants. We also reviewed six sets of patient records.