Bolton NHS Foundation Trust

Bolton NHS Foundation Trust provides a range of hospital and community health services in the North West sector of Greater Manchester, delivering services from the Royal Bolton Hospital (RBH) site in Farnworth, in the South West of Bolton, close to the boundaries of Salford, Wigan and Bury; as well as providing a wide range of community services from locations within Bolton.

The Royal Bolton hospital site is situated in the town of Farnworth, near Bolton. For services, in particular patients requiring non elective treatment, it is estimated to have a catchment population of 310-320,000, compared with a resident Bolton population of 270,000.

The Royal Bolton hospital provides a full range of acute and a number of specialist services including urgent and emergency care, general and specialist medicine, general and specialist surgery and full consultant led obstetric and paediatric service for women, children and babies, including level three neonatal care and 24-hour paediatric and consultant-led obstetric services .

At Bolton NHS Foundation Trust, the Integrated Community Services Division consists of domiciliary, clinic and bed based services across the Bolton footprint to GP registered population. Most services are commissioned via Bolton Clinical Commissioning Group. The trust worked in partnership with Bolton Council, Greater Manchester West, North West Ambulance Service and with the voluntary sector such as Age Concern and Urban Outreach. The Division had approximately 420 Staff (380.46 whole time equivalent) and had a budget of £16.8 million.

Approximately 110,000 people attend the trust for emergency treatment every year and 72,000 patients are admitted. Approximately 310,000 attend the outpatient departments for consultations. The Royal Bolton Hospital has approximately 740 beds and employs 5200 staff.

We visited the hospital on 21- 24 March 2016. We also carried out an out-of-hours unannounced visit on 6 April 2016. During this inspection, the team inspected the following core services:

• Urgent and emergency services

• Medical care services

• Surgery

• Critical care

• Maternity and gynaecology

• Children and young people

• End of life

• Outpatients and diagnostic services

• Community Adults

• Community adult inpatient services

• Community children and young people

• Child Adolescence mental health services

Overall, we rated Bolton NHS Foundation Trust as good for services it was providing.

We rated Royal Bolton Hospital as good over-all. We have judged the service as ‘good’ for effective, caring, responsive and well led. We found that services were provided by compassionate, caring staff and patients were treated with dignity and respect. However, improvements were needed to ensure that services were safe.

We rated Bolton One as good for all key questions safe, effective, caring, responsive and well-led.

We rated community inpatients, community adults and children and young people as good in all 5 domains.

We rated the child adolescent mental health service as requires improvement in safe, effective, responsive and well-led domains, and good in the caring domain.

Our key findings were as follows:

Leadership and Management

• There was a positive culture and a sense of pride throughout teams across the trust, and staff were committed to being part of the trusts vision and strategy going forward.

• There was effective teamwork and clear leadership and communication in services at a local level. Managers and leaders were visible and approachable. Staff we spoke to felt supported by their managers and supported and encourage to raise concerns and ideas.

• The trust was led and managed by an executive team that were approachable and visible. All staff we spoke to knew the team and felt that they were listened to and concerns were acted upon. All staff spoke with the highest regard for board members, and gave examples of positive interactions and collaborative working between the board and staff in order to improve safe care and treatment and outcomes for patients.

Culture

• There was a very positive culture throughout the trust. Staff of all grades were committed to continually making improvements to the quality of care delivered.

• There was a supportive culture across divisions, and staff worked collectively to identify quality improvements and help deliver services safely on a day-to-day basis.

• Staff were proud of the services they delivered and proud of the trust.

• There was a range of reward and recognition schemes that were valued by staff. Staff were encouraged to be proud of their service and celebrate their achievements.

Equality and Diversity

• The Director of Nursing was executive lead for equality and diversity. There was a strategy in place  which was monitored though the equality and diversity inclusion steering group and the patient experience, inclusion and partnership committee.
• We found that the trust had a positive and inclusive approach to equality and diversity. We found that staff were committed and proactive in relation to providing an inclusive workplace.
• There were a range of staff groups and patient groups that contributed to the trust equality, diversity and inclusion agenda, which included learning disability patient groups, people living with dementia and young people accessing adolescent mental health services (CAMHS).
• The trust had key objectives aligned to the public sector equality duty and equality delivery system (EDS2), and had audit and monitoring systems in place against key metrics, for example diversity of patients, complaints and patient feedback in order to understand the quality of care and service being provided. We saw that good progress had been made against the EDS2 standards.
• As part of the new Workforce Race Equality Standard (WRES) programme, we have added a review of the trusts approach to equality and diversity to our well led methodology. The WRES has nine very specific indicators by which organisations are expected to publish and report as well as put action plans into place to improve the experiences of it Black and Minority Ethnic (BME) staff. As part of this inspection, we looked into what the trust was doing to embed the WRES and race equality into the organisation as well as its work to include other staff and patient groups with protected characteristics.
• We analysed data from the NHS Staff survey regarding questions relating to the Workforce Race Equality Standard (WRES). The results for the trust were positive for the trust in most areas.
• However, there had been an increase in all staff experiencing harassment, bullying or abuse from patients, relatives or the public in the last 12 months. There had been a notable increase in reports from staff from a BME background from 25% in 2014 to 39% in 2015. Similarly, the percentage of staff experiencing harassment, bullying or abuse from staff in last 12 months had shown a small increase for all staff, however BME staff reporting bullying had gone up from 26% to 36%.
• The trust had acted upon findings from the national staff survey as part on ongoing range of actions in place to support staff engagement. Examples included a non-executive director responsible leading whistleblowing concerns and a new appointment of a “speak up guardian” would further support staff in being able to raise concerns.
• All staff we spoke to felt well supported, able to raise concerns and develop professionally.

Governance and risk management

• Governance and risk management structures were embedded in the trust.
• There was a robust committee structure in place that supported challenge and review of performance, risk and quality. Mechanisms were in place to ensure that committees were led and represented appropriately, to ensure that performance was challenged and understood.
• The trust had a pro-active approach to risk management with clear roles and responsibilities and monitoring arrangements in place. We observed a particular area of good practice, in which all new incidents and risks were reported to board members daily. Within this, a second report was circulated within the day reporting key actions that had been taken. This pro-active approach meant that board members were clear on strategic and operational risks at the earliest opportunity.
• The Board Assurance Framework (BAF) was aligned to strategic objectives and we saw evidence that it was linked appropriately to divisional risk registers that were regularly reviewed. We observed that the trust did not have an over-all trust risk register, however processes were in place to ensure that both operational and strategic risk and performance issues were reported and acted upon though monthly management meetings chaired by the chief executive.
• Board assurance related to the BAF and strategic and operational objectives were tested in practice by board members and governors. This was done though a formal programme of work which was aligned to current themes and risks. Staff said they found this supportive and felt that the board understood operational issues and this approach created a collective approach to decision making.
• There were divisional governance meetings where performance, risks and learning was discussed and shared. Staff had access to robust data to support good performance which included thematic reviews and correlation of data to promote early identification of poor performance. We observed that whilst this was being used well operationally, there may be a missed opportunity to prospectively use data to further to support trust wide initiatives, however the trust’s current information technology systems limited real-time information across the trust.

Mortality rates

• Mortality and morbidity reviews were held in accordance with trust policies and were underpinned by robust and well understood procedures. All cases were reviewed and appropriate changes made to help to promote the safety of patients and prevent avoidable deaths. Key learning Information was cascaded to staff appropriately. Monitoring arrangements were in place at board level to ensure that any findings were acted upon.
• The Summary Hospital-level Mortality Indicator (SHMI) is a set of data indicators, which is used to measure mortality outcomes at trust level across the NHS in England using a standard and transparent methodology. The SHMI is the ratio between the actual number of patients who die following hospitalisation at the trust and the number that would be expected to die based on average England figures, given the characteristics of the patients treated at the hospital. The risk score is the ratio between the actual and expected number of adverse outcomes. A score of 100 would mean that the number of adverse outcomes is as expected compared to England. A score of over 100 means more adverse (worse) outcomes than expected and a score of less than 100 means less adverse (better) outcomes than expected. In November 2015, the trust score was 104.

Nursing and midwifery staffing

• The trust undertook biannual nurse staffing establishment reviews using a recognised evidence based tool as part of mandatory requirements. Key objectives were set though this work to support safer staffing and address and mitigate identified shortfalls and support recruitment.
• The trust was in the process of implementing a daily acuity tool to further support safer staffing levels based on patients acuity and needs.
• There were processes in place to ensure ward staffing levels were monitored on a daily basis. Senior nurses and matrons met each week to discuss nurse staffing levels across services to ensure that that there were sufficient numbers of staff.
• Staffing on a day to day basis was reviewed as part of the trust bed management meetings. Shortfalls were subject to management action and risk mitigation.
• However, nurse staffing levels remained a challenge, particularly in emergency, medical and the paediatric department. Nursing staffing was identified on both operational and corporate risk registers. At the time of this inspection there were 50 nursing staff vacancies across the trust and additional posts had been made available in order to support the increased requirements across the across the acute hospital.
• Staffing levels were maintained by staff regularly working extra shifts and with the use of bank or agency staff. Inductions were in place for new staff in order to mitigate the risk of using staff that were not familiar with the trust’s policies and procedures.

Medical staffing

• Whilst most areas had sufficient numbers of medical staff to meet patients needs, which included the use of agency staff, there were pressures within the emergency department due to increased demand.
• Increased activity in the emergency department had meant that emergency department consultants were regularly working in place of middle grade staff to ensure the department continued to function with appropriate medical staffing levels. We observed that medical staff were committed to maintaining patient safety and worked well together as a team to ensure that rotas were covered.
• A recent review by the Royal College of Emergency Medicine had recommended an increase in establishment of consultants of 6.5 WTE, which was being considered at the time of this inspection. In addition, it had been recommended to increase medical middle grade staffing by five WTE. Whilst the shifts we reviewed showed that staffing levels were sufficient. We were concerned that the current use of consultants to fill middle grade shifts may not be sustainable in the long term.
• The trust board had recently authorised recruitment for two middle grade doctors and relaxed the cap on locum use to assist with staffing. However, managers described difficulties recruiting due to the high volume of patients attending the ED compared with other EDs.

Access and flow

• The trust had established policies and both internal and external escalation procedures in place to support patient flow and movement across the trust. This included established escalation meetings and a designated site manager co-ordinating patient flow.
• Access and flow remained a challenge, and the emergency department did not, at times see, treat, admit or discharge patients within the national target of four hours.
• Plans were in place to expand the emergency department in order to accommodate the increase in patient attendances, including the increase in patients attending from outside of Bolton.
• There were some pressures with access and flow across the medical and surgical wards, including patients who were medically optimised and ready for discharged. Access and flow issues resulted in a number of patients being cared for on a ward outside of their speciality. There were policies and procedures in place outlining the management of these patients to ensure that the appropriate medical teams saw patients regularly and appropriately.
• The overall hospital-wide bed occupancy rate between July 2013 and December 2015 ranged between 80.8% and 88%, which rose to 91% on medical wards between January and March 2016.
• In spite of pressures, we observed that the average length of stay for elective medicine at the hospital was shorter (better) than the England average at 2.9 days.
• NHS England data showed the surgical and gynaecology services consistently performed better than the England average for 18-week referral to treatment standards for admitted (adjusted) patients between November 2014 and January 2016.
• Most patients were admitted to the intensive care unit within four hours of making the decision to admit them and a consultant assessed 100% of patients within 12 hours of admission.
• Diagnostic waiting times had been consistently better than the England average between January 2014 and November 2015.
• The trust had performed consistently better than the England indicators for incomplete pathway referral to treatment times between December 2014 and November 2015.
• Activity measures within the community services indicated that, in Bolton, the team were above the trust target for the number of GP referrals that were received (6,501 against a target of 6,187). The service indicated that these figures had been impacted on in view of the new initiative they had trialled with GPs for keeping patients out of hospital.

Cleanliness and infection control

• Clinical areas at the point of care were visibly clean, trust had infection prevention, and control policies in place, which were accessible to staff and staff were knowledgeable on preventing infection.
• There was enough personal protective equipment available such as aprons and gloves that were accessible for staff and was used appropriately.
• Staff followed good practice guidance in relation to the control and prevention of infection in line with trust policies and procedures.
• Between April 2015 and December 2015, the trust reported 19 cases of Clostridium difficile, four cases of Methicillin-resistant staphylococcus aureus (MRSA) and 18 cases of Methicillin-susceptible staphylococcus aureus (MSSA) which were in line with local and national trajectories.
• Lessons from all cases were disseminated to staff for learning across directorates .
• There were established audit programmes in place related to the prevention of cross infection, which included hand hygiene, infections within a central line (a long, thin, flexible tube used to give medicines, fluids, nutrients, or blood products) and methicillin-resistant Staphylococcus aureus (MRSA).

We saw several areas of outstanding practice including:

• The emergency department 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, for example, details of their current medicine.
• The emergency department offered bereavement meetings were offered to those who had lost a loved one, to help them understand what had happened.
• Emergency department Consultants were regularly working in place of middle grade staff to ensure the department continued to function with safe medical staffing levels.
• The radiology department had a managed equipment programme in place. This meant that equipment was serviced, repaired and replaced as part of the contract in a timely way, minimising disruption to services and reducing the need for costly and time consuming business cases when equipment needed replacing. This was an innovative way of managing high cost equipment.
• The trust were early adopters of the newborn behaviour assessment tool (NBAS).
•  The neonatal unit were early adopters of volume ventilation.
• The neonatal unit introduced ‘Matching Michigan’, a two-year programme designed to reduce infections in central lines, before it was rolled out as best practice. As a result ,the service was nominated for an award from the Health Service Journal (HSJ).
• The neonatal unit introduced the ‘fresh eyes initiative’, which is where nursing staff look at other nurses’ patients at 1am and 1pm to promote things not being missed.
• Any incidents with an initial grading of harm were circulated to all trust board members on a daily basis. Initial information was received before 9am and then follow information on what actions had been taken were received by 10.30am.

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

Importantly, the trust must:

• Complete mental health assessment forms in the emergency department as soon as practicable and ensure these are distributed and used where appropriate.
• Improve staffing levels in the emergency department with an aim to reducing agency and locum rates.
• Improve appraisal rates in the emergency department.
• In the emergency department, Improve the focus on audits, ensuring clear action plans are formulated and progress regularly tracked to improve outcomes.
• Ensure that robust information is collected, analysed, and recorded to support clinical and operational practice in medical services.
• Deploy sufficient staff with the appropriate skills on wards.
• Ensure that records are kept secure at all times so that they are only accessed and amended by staff.
• Ensure that staff are up to date with appraisals and mandatory training in medical wards.
• Ensure that paper and electronic records are stored securely and are complete in outpatient’s areas.
• Ensure that essential safety checks are completed and records of checks are maintained to provide assurance that all steps are being taken to maintain patient safety in outpatients.

Professor Sir Mike Richards Chief Inspector of Hospitals

Overall we rated adult community services as good because:

• All community staff were aware of the trust’s incident reporting processes and there were mechanisms in place to learn from incidents.

• We found compassionate and respectful care was present in all interactions we observed.

• Patients accessing the service received effective care and treatment that followed national clinical guidelines including those from the National Institute for Health and Care Excellence (NICE). The service planned its services to meet the individual needs of the local population it served.

• Patients had access to the right care at the time and where targets in respect of this were not met, the service was working to improve and evidence of this improvement was well documented.

• There were robust governance frameworks and managers were clear about their roles and responsibilities.

• Risks were appropriately identified, monitored and there was evidence of action taken, where appropriate.

However,

• There were some instances where records were not fully completed in accordance with best practice.

• Staff did not always have timely access to computers.

We rated the community children and young people services at the Bolton NHS foundation trust as ‘Good’.

This was because: -

• The level of incidents reported showed low risk of harm and safe systems for care and treatment of patients. Staff understood how to report incidents.

• There were enough suitably skilled, competent staff with the right mix of skills to meet patients’ needs.Patients were treated in clean and suitably maintained premises. Patient records were complete and accurate.

• The care and treatment was based on national clinical guidelines and staff used care pathways effectively. Audit records showed most patients experienced positive outcomes following their care and treatment and appropriate actions were taken to improve compliance with best practice standards

• Services were planned and delivered to meet the needs of local people. There were systems in place to support vulnerable patients. Most patients received care and treatment in a timely manner.

• Patients and their relatives spoke positively about the care and treatment they received. They were treated with dignity and compassion. They were kept involved in their care and they were supported with their emotional needs.

• The service delivery was based on the trust values and core objectives and staff had a clear understanding of what these involved. There was clearly visible leadership in place through local team leaders and staff were positive about the culture and support available.

However;

• Only 70% of staff in the Children's Community Nursing service had received their level three safeguarding children training.

• Some staff experienced difficulties in accessing trust-wide IT systems due to connectivity issues.

• There was a gap in compliance for nocturnal enuresis (bed-wetting) in children and young people because of an issue with alarms.

We rated specialist community mental health services for children and young people as requires improvement because:

• The trust did not provide eligible staff with mandatory training in safeguarding vulnerable children at level three. NHS England identified that this training is essential for the role of a community CAMHS practitioner.

• The trust did not provide eligible staff with mandatory training in the Mental Health Act (MHA), MHA Code of Practice (2015), Mental Capacity Act or legal frameworks specific to children and young people aged below 16 years, such as the Children’s Act (2004).

• The trust had a MHA policy in place. However, staff did not always follow the MHA Code of Practice (2015).

• CAMHS had a lone working policy in place. However, staff did not always follow this in practice.

• Once assessed by the single point of access team (SPoA), children and young people had to wait approximately 23 weeks to receive active treatment from a CAMHS practitioner.

• Children and young people’s care plans did not always capture their views.

• The local population comprised of approximately 30% of people who identified as black or a minority ethnicity (BME). CAMHS received very few referrals from children and young people who identified as a BME.

• Outcome measures to monitor the progress children and young people were making whilst receiving treatment were not routinely completed.

• In some key areas, CAMHS were not working proactively with other teams within Bolton NHS Foundation Trust to improve the service they delivered to children and young people.

• During inspection, we found a sharps box (a box used to dispose of contaminated items such as used needles and syringes) that had not been disposed of since 2014. This increased the risk of the spread of infection within the service.

• The main units clinic room did not have a mixed water tap.The Department of Health guidelines (Infection control in the built environment 2013) states that mixed water taps are essential for reducing the risk of scalding to people using the facility.

However;

• Staff completed comprehensive risk assessments for every child and young person that used the service, and these were regularly reviewed. There was an effective on-call system to respond to any emergencies within the service.

• Staff were effective in the prescribing and monitoring of children and young people on medications.

• Staff were well qualified to perform their role.

• CAMHS had improved its working relationship with other agencies, external to the trust, that were also involved with children and young people using the service. This included delivering training to local primary and secondary schools to raise mental health awareness.

• Staff treated children, young people and their parents/carers with kindness, dignity and respect.

• Children, young people and their parents/carers had produced short films for the CAMHS website to raise awareness of what it was like to access CAMHS and the different kinds of support they offered.

• The service demonstrated a commitment to quality improvement and innovation. The patient participation group had successfully secured funding from the Health Education Innovation England Fund (2015/16) to develop a self-help mobile phone application.

Overall rating for this core service

Community inpatient services were rated as good overall. This was because;

• The service used the NHS safety thermometer to monitor its performance in relation to safety. Action plans were in place to improve harm free care.

• Incidents were reported and learning was shared. There was a good reporting culture. Incidents were investigated in a timely way.

• The environment was visibly clean and tidy. We saw staff using personal protective equipment such as aprons and gloves and observed them washing their hands appropriately. Hand hygiene compliance audits were high. Medicines were stored correctly and securely.

• A new nurse call buzzer was in place to improve patient safety.

• Overall mandatory training rates met the trust target. Adult safeguarding level two had been completed by 96% of staff. Staff we spoke with understood their responsibilities in relation to safeguarding adults.

• There were systems in place to ensure that patients were assessed and risks were monitored and minimised. There were clear admission criteria to ensure patients could be safely cared for outside of an acute hospital environment.

• A daily safety huddle involving key members of the multidisciplinary team was in place to highlight particular patient safety concerns.

• Nursing staffing fill rates were generally good. Nursing staff were supported by staff from the local authority.

However,

• Risk assessments were not always completed in a timely way, for example the risk of developing a pressure ulcer.

• There was not sufficient structure to intentional rounding documentation to ensure this essential patient safety task was completed in an effective way.

• The environment required the planned upgrades to ensure patients could be cared for in a safe way.

We rated effective as good because;

• Audits of care were completed and showed that 100% of patients had an individualised care plan.

• Care and treatment followed evidence based practice and national guidance. A consultant provided a ward round twice weekly.

• Pain was monitored and pain relief given in a timely way.

• There was access to additional training to improve staff knowledge in areas such as falls and dementia care.

• Multi-disciplinary working was well-established. The service worked well with colleagues from the local authority.

However;

• Appraisal rates did not meet the trust target.

We rated caring as good because;

• Friends and family test scores showed a high percentage of patients would recommend the service.

• Patients and those close to them were involved in their care and treatment. A care co-ordinator acted as a point of contact.

However;

• Scores for privacy and dignity on the patient led assessment of the care environment (PLACE) were much lower than the England average although details from the trusts own survey showed that patients felt they were treated with dignity and respect.

We rated responsive as good because:

• Services were planned around the needs of local people. There was additional capacity at times of high demand for intermediate care beds.

• Individual needs were understood and considered when delivering care and treatment. There was additional facilities and support for patients living with dementia.

• The service monitored admissions and discharges. This information was shared with staff at the hospital to improve access and flow.

• There were low numbers of complaints about Darley Court. Lessons were learnt from complaints and shared within the division and the wider trust.

However,

• The environment required improvements to better meet the needs of patients living with dementia.

We rated well-led as good because:

• Governance and risk management systems were in place that supported the delivery of care. Risks were managed and regularly reviewed to minimise the impact to the service.

• Leaders used comprehensive performance dashboards to monitor how the service was doing. The service had good systems in place to review data about patient referrals and outcomes.

• Leaders were supportive and enthusiastic about the service they provided. They valued every member of the team.

• The culture was open and honest. Staff engagement was good.

• The service was working closely with local partners to improve, develop and ensure a sustainable service for the future.

However,

• Issues with IT meant that leaders could not always look at data relating solely to Darley Court.

• There had been no recent patient experience survey.