Northern Care Alliance NHS Foundation Trust

Salford Royal NHS Foundation Trust provides both acute and community services to a population of 240,000 people across Salford and the surrounding areas of Greater Manchester. The trust serves a national population for those requiring some specialist care for the treatment of disease or disorders of the brain, skin, renal system, spine and those with intestinal failure conditions.

Salford Royal NHS Foundation Trust employs around 6,600 whole time equivalent staff across both the acute hospital and community services. Of these staff there are 730 medical staff, 2,200 nursing staff, 2,000 care support staff and 350 allied healthcare professionals.

We carried out this follow-up inspection in addition to our comprehensive inspection which we undertook in October 2013, as Salford Royal Hospital was inspected during a pilot period when shadow ratings were not published. In order to publish a rating we needed to update our evidence and inspect all of the core services that are provided by Salford Royal Hospital. In addition, we had not inspected the community services provided by the trust during our inspection in 2013. Our methodology included an unannounced visit carried out on the evening of 27 January 2015 and a public listening event. At the public listening event we heard directly from approximately 60 people about their experiences of care.

We have rated the trust overall as outstanding. The Salford Royal Hospital was rated as outstanding and the community services as good. On CQC's five key questions safe and effective were rated as good, while caring responsive and well led were judged to be outstanding at trust level. In relation to core services, A&E, medicine and end of life care in the acute hospital and adult services and end of life care in the community were each rated as outstanding..

Throughout this trusts reports, reference will be made to the Nursing Assessment and Accreditation System (NAAS) and the trust wide initiative to provide safe, clean and personal care every time (SCAPE).. The Nursing Assessment and Accreditation System (NAAS) is a performance framework system designed to help nurses in practice by measuring the quality of nursing care delivered by teams. This performance assessment framework is based on the Trust’s Safe, Clean, Personal approach to service delivery and combines Key Performance Indicators and Essence of Care standards. The framework is designed around 13 standards with each standard subdivided into three elements: leadership, care and environment. The assessment consists of observations of care, asking patients and staff relevant questions, observing meal delivery, and receiving patient feedback. Wards and departments are rated from red (worst) to blue (SCAPE – best). Where we have reported that wards have attained SCAPE status, this indicates that the ward has been assessed over a period of at least 24 months, and during each assessment, had attained at least a green rating (good). Three consecutive green assessments result in SCAPE status being awarded.

For a ward to achieve SCAPE status they must, as a minimum, have maintained NAAS (green) for 24 months. Further assessments are undertaken using a comprehensive set of standards for nursing care and the teams can then apply for SCAPE. A SCAPE panel (consists of board members, senior multi-professional staff and a member of the public) then reviews the teams and makes recommendations to trust board that will approve, defer or decline SCAPE status for the applying area.

Leadership of the Salford Royal Hospital was rated as good overall with three core services that each demonstrated outstanding leadership; two core services that were rated as good and two core services that required some improvements to be made. The community leadership was rated as outstanding overall; trust-wide leadership was evident to be outstanding. The aggregation of these judgements for assessing well-led at provider level is outstanding overall. Combining the overall ratings of outstanding for caring, responsive and being well-led results in the overall trust being rated as outstanding.

Our key findings were as follows:

Safe:

• The concept of providing safe, harm free care was considered as a priority by all members of staff. Through the use of quality improvement programmes, we found many examples of how staff had worked together to ensure they provided safe care.

• The use of internal governance systems to ensure that safe care was being provided was well embedded. Nursing assessment and accreditation systems (NAAS) provided the trust board and patients a high level of transparency in relation to clinical performance indicators and measures. This information was publicised throughout the wards and clinical areas for people to consider.

• In conjunction with the NAAS initiative, staff spoke positively about ensuring that patients received safe, clean and personal care every time (SCAPE). SCAPE was described as a process lasting 24 months and involving three separate assessments whereby staff delivered on a range of patient focused competencies and considered a range of performance indicators. The accolade of SCAPE was seen as significant success by clinical leaders and ward based staff.

• The hospital was visibly clean and staff were witnessed to follow appropriate infection control practices. Audits were routinely undertaken to ensure staff complied with local and national policies and action was taken if areas of concern were identified.

Effective:

• Staff based cared on best practice guidance. A robust audit programme was in place to demonstrate that where improvements were required, action was taken and outcomes monitored to determine effectiveness. The trust benchmarked itself against a range of national comparators; this demonstrated that the trust generally performed the same as, or better than others in many areas.

• Multidisciplinary working was strongly embedded across the trust. The provision of integrated care through the development of Salford Health Care was demonstrable of the abilities of the trust to provide care through multidisciplinary working.

Caring:

• There was a strong emphasis on providing caring, compassionate and dignified care to patients. Performance against national patient satisfaction surveys was consistently good across of all core services with the exception of children and young people’s services where further work was required to seek the feedback from children and their parents/carers.

• People who used the services were actively involved in developing improvements in their care to ensure the care they received was personal. In January 2013 the trust launched a project aimed at improving patient, family and carer experience as part of the patient experience strategy.This resulted in the concept of ‘always events’, which were things that patients should always expect to happen to them when in receiving care from the trust

Responsive:

• Services were able to assess and respond to the needs of the population they served. Feedback was sought from patients and relevant stakeholders to enhance services.

• Provision of religious and spiritual support and the support of patients during the end stages of life was noted as being particularly outstanding.

• The critical care department provide a combination of ward, telephone and outpatient multidisciplinary follow up service.They contributed to the development of NICE guidelines (2009) on critical care rehabilitation. They proactively gather feedback on the service for evaluation.

• The hospital had a multi-faith centre which catered to the religious needs of the local population including a non-denominational ‘Oasis’ room.

• A blue butterfly symbol was introduced within the trust to identify service users with cognitive impairment. Patients identified as such, were visited by dementia specialist nurses who also co-ordinated training for staff members on dementia awareness. All wards had a dementia champion.

• Patient passports were in use across the trust, including passports in different languages.

• The trust had a rigorous complaints answering process to address both formal and informal complaints. Each department had a lead nurse in charge of reviewing and acting on complaints and disseminating the learning from the complaints through safety huddles and newsletters.

Well-led:

• Quality improvement was a clear focus for the trust through collaboration across all staff groups in quality improvement methods to reduce patient harm, improve outcomes and patient experience.One ‘collaborative’ focussed on gathering patient views across the whole pathway of care from prior to admission to the community to make improvements

• Members of the senior management team were fully engaged with ‘front-line’ staff. Strong working relationships had been developed between the trust executive team and the Foundation Trust Governors. Governors were clear about their roles and purpose which enabled them to contribute to the success of the trust.

• The ambition and vision of the trust to be the safest trust in the National Health Service was understood and embedded in the practices of staff across all professions and at all levels of seniority.

• Staff spoke positively about the engagement of the management team which enhanced a culture of innovation; high staff satisfaction rates were representative of the positive feedback we received from staff during the inspection.

• The trust had a clear vision and strategy for quality improvement within the trust and for working with partners across Wigan, Bolton and Salford and more widely.

• The trust has some of the best scores in the country on the staff survey, reflecting the positive culture in the organisation.

We saw several areas of outstanding practice including:

• Nursing assessment and accreditation systems (NAAS) provided the trust board and patients a high level of transparency in relation to clinical performance indicators and measures. This information was publicised throughout the wards and clinical areas for people to consider and scrutinise.

• In conjunction with the NAAS initiative, staff spoke positively about ensuring that patients received safe, clean and personal care every time (SCAPE). SCAPE was described as a process lasting 24 months and involving three separate assessments whereby staff delivered on a range of patient focused competencies and considered a range of performance indicators. The accolade of SCAPE was seen as significant success by clinical leaders and ward based staff.

• There was clear evidence that the development of the ’emergency village’ with its integrated care pathway approach, including medical in-reach, continued to deliver improved outcomes for people.

• Quality improvement initiatives had successfully led to a reduction in the number of hospital acquired pressure ulcers.

• Staff were encouraged to undertake research, for example, we reviewed a paper published in respect to improving patient care in a national intestinal failure unit.

• The surgical division celebrated the positive arrangement they had for the movement of elective orthopaedic work off site and anticipated this would improve patient throughput, standardise use of prosthetics and develop a centre of excellence.

• The surgical division indicated they had established a link with Central Manchester NHS Foundation Trust, which they anticipated could lead to future partnership working in their developed Manchester Orthopaedic Centre.This was expected to lead to increased pooled volumes of specialist activity with standardised practice leading to improved patient outcomes.

• The surgical division annual plan described the development of a service model for emergency and complex surgery with two other NHS providers.

• We saw in the theatre staff newsletter produced for December 2014 an introduction to the forthcoming ‘Theatre Improvement Programme’. We were told this was due to commence at the end of January 2015, with the aim of ensuring theatres could provide safe and reliable care, provide value and efficiency and deliver a high team performance with high team morale and well-being.This work was being co-ordinated and delivered through a Quality Improvement methodology, led by a steering group headed by the Director of Organisational Development and Corporate Affairs. We saw from information provided to us that the programme was based around the Productive Operating Theatre model, developed by the NHS Institute for Innovation and Improvement.

• The senior managers within the surgical directorate recognised the areas for further focus, which included interventional radiology, middle grade recruitment to medical staff, the delivery of complex emergency care and making improvements to the discharge process, by reviewing and enhancing the patient pathway.

• There was an incentive for staff who wished to be involved in helping the trust to make financial savings to the service. If an idea was adopted, the staff member received 10% of the overall savings as a reward for their innovation.

• Rotating junior staff to other areas across the critical and high dependency care units to facilitate personal progression and encourage staff retention.

• Bleeps were provided to relatives in order that they could be contacted quickly by staff if they were away from the CCU.

• The diabetes outpatient service demonstrated good practice where children in transition from young people to adulthood were seen in a clinic attended by an adult physician and adult specialist nurses, giving dietetic and psychological support. This ensured a continuous and consistent pathway of care through to adulthood.

• We were told the trust was actively engaged in the NHS Improving Quality ‘Transform Programme’ (Phase 2).This programme aims to encourage hospitals to develop a strategic approach to improving the quality of end of life care. The Trust had pilotedthe use of AMBER (Assessment Management Best practice Engagement Recovery uncertain) Care Bundles (ACB) which were used to support patients that are assessed as acutely unwell deteriorating, with limited reversibility and where recovery is uncertain however it was decided not to continue to implement the ACB after the pilot.

• Other improvement areas include Advance Care Planning (ACP), EPaCCS, rapid discharge pathway, meeting the priorities for care of the dying person and effective care after death including bereavement and mortuary service.

• Innovative work undertaken included the access to seven day Specialist Palliative Care for SRFT since 2009 (only 21% of trusts deliver this nationally). The trust has participated in all 4 rounds of the NCDAH and the trust was described as above the national average for 9 out of 10 Clinical KPI’s. The bereavement care delivered across the trust and the trusts awareness around cultural needs of the population were well met by the HSPC, bereavement and the chaplaincy teams.

• The system of daily safety huddles, and intra-team situation reports ensured that important information was passed between teams and shifts.

• The team-based audit programme and the monitoring of results and actions.

• The Community Assessment and Accreditation System, and arrangements for gathering patient feedback.

• The mandatory training and professional registration monitoring systems.

• The system of competency assessment and associated records.

• The use of the “Butterfly Scheme” for people living with dementia.

• The arrangements for ensuring the safety and security of lone workers in community adult services.

• The Care Home Medical Practice was a beacon of innovation and excellence, reducing unplanned hospital admissions and supporting people to remain in their preferred place of care until their death.

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

Action the hospital MUST take to improve

• The trust must take action to ensure that WHO safety checks (or equivalent) are conducted on all patients going through operating theatres and must take action to ensure that monitoring of WHO safety checks are carried out.

• The trust must ensure that the environment is appropriately maintained and fit for purpose; the main out-patient department experienced a regular leaking roof in several areas, and sewage leaks through the ceiling.

Action the hospital SHOULD take to improve

• The trust should ensure that safety checks on technical equipment used in the delivery of treatment and care to patients is carried out routinely. This is something that is required as part of Regulation 16, safety, availability and suitability of equipment. It was considered that the omissions related to the checking of anaesthetic machines by theatre staff was not proportionate to support a judgement of a breach of the regulation.

• The trust should ensure that the knowledge and application of the Mental Capacity Act and the Deprivation of Liberty Safeguards is consistently applied across all services.

• The trust should ensure that it makes consideration of improving the discharge process to patients from the wider geographical area, beyond the local service area.

• Whilst we acknowledge that the Trust has embarked on a programme of quality improvement within theatres to improve the culture and morale, the trust should ensure that this initiative is both effective and sustainable so that changes are fully embedded for the future.

• The trust should consider ways of reducing the rate of surgical procedure cancellations.

• The trust should consider a unified strategy for the delivery of children’s services, both medical and surgical; governance systems, risk management and performance measurement processes should be standardised to ensure children receive quality, evidence based care.

• The provider should consider arrangements for the management of patient records at Walkden Gateway.

• The provider should consider how discharge information between the acute and community sectors could be made more effective.

• The provider should ensure that patient records at Swinton Hall are appropriately secured and kept safe.

• The provider should review its current storage arrangements at Heartly Green to ensure equipment is stored appropriately and safely.

• The provider should review existing arrangements with regards to the supply of medicines at Heartly Green to ensure medicines are made available without unnecessary delay.

• The provider should ensure that all Control Drug log books are maintained in line with national requirements.

• The trust should review existing pathways to ensure that children who were not in mainstream education were appropriately identified in order that their health and development needs can be identified and assessed in line with national programmes.

Professor Sir Mike Richards

Chief Inspector of Hospitals

We visited a sample of Community Adult Services on 13/14th January 2014. We held two focus groups with a range of staff who worked within the service. We talked with about 35 people who use services (including 13 telephone interviews) and four carers. We spoke with six managers, and about 20 registered and four unregistered staff. We observed how people were being cared for in clinics and in their own homes and reviewed care or treatment records of people who use services.

We judged that Community Adult Services were outstanding. This was because we found that there arrangements to ensure that patients were safe, and that there were systems to report, investigate and learn from safety incidents and near-misses. We found that care and treatment was based on current guidance and best practice and there were arrangements to monitor the standards of care. Patients told us that they were treated with kindness and empathy and that their dignity was upheld. Services were arranged to respond to patients’ individual needs and could be accessed when they were required. We found that services were well-led, with a positive culture with a clear vision, values and strategy which staff were engaged in and identified with. There were robust governance systems that ensured information flowed freely between the various levels of management, including the executive team and front-line staff.

We have rated the community adult inpatient service provided by Salford Royal NHS Foundation Trust as good. We found that there were appropriate arrangements in place to ensure the safety and wellbeing of patients. Governance systems were suitable robust to ensure that where incidents occurred, these were investigated, lessons were learnt and changes in practice were communicated to staff. Care and treatment was based on current guidance and best practice. There were arrangements in place to audit care to determine its overall effectiveness. Patients told us that they were treated with dignity and compassion and that they were involved in the planning of their care. Services were well-led; staff demonstrated and exuded a ‘can-do’ attitude which was based upon providing safe care to their patients.