Nottingham University Hospitals NHS Trust

Nottingham University Hospitals NHS Trust is the fourth largest acute trust in England and provides services to more than 2.5 million residents of Nottingham and its surrounding communities. It also provides specialist services to between three and four million people from neighbouring counties. The trust is based in the heart of Nottingham on three separate sites around the city: Queen’s Medical Centre, Nottingham City Hospital and Ropewalk House. Queen’s Medical Centre is the emergency care site, where the emergency department, major trauma centre and the Nottingham Children’s Hospital are located.

Nottingham University Hospitals NHS Trust is registered to provide the following Regulated Activities:

• Diagnostic and screening procedures

• Family planning

• Maternity and midwifery services

• Surgical procedures

• Termination of pregnancies

• Treatment of disease, disorder or injury.

• Assessment or medical treatment for persons detained under the Mental Health Act 1983

Nottingham University Hospital NHS Trust were inspected as one of 18 CQC new wave pilot inspections in November 2013 but the trust was not rated at this inspection. The purpose of this comprehensive inspection was to award a rating to the trust for the services it provided. We carried out an announced inspection to the three hospital locations between 15 and 18 September 2015. Unannounced visits were carried out on 28 September to medical wards, children’s wards and the maternity department.

Overall, this trust was rated as “Good.” We made judgements about 16 services across the trust as well as making judgements about the five key questions that we ask. We rated the key questions “are services safe as requires improvement. We rated the key questions, “are services effective, caring and responsive” as good and we rated the key question “are services well led as outstanding.

Our key findings were as follows:

Cleanliness and inspection control

• Staff mostly followed infection prevention and control policies and cleansed their hands between patients.

• Equipment was cleaned following use and was labelled appropriately.

• In most areas clinical waste was suitably managed however at the City Hospital we found that clinical waste areas were not secure.

• Cleaning services were contracted out to a private provider. There had been problems with cleanliness prior to and following our inspection which were identified through the trusts own audits and those carried out by the Trust Development Authority. These were been monitored and action was being taken to improve. Progress was been closely monitored by the executive team. During our inspection, we generally found the hospitals to appear visibly clean.

Staffing levels

• Like many trust in England, there were shortages in some areas for doctors, nurses and allied health professionals. Some areas had higher vacancy levels than others. Generally we found that vacancies were managed well. There was a clear escalation process in place which staff knew how to use.

• The trust were in the process of rolling out an innovative new electronic staffing level monitoring tool. This enabled real time information to be available regarding the staffing levels and the wards that required more resource.

• There were different approaches to managing any shortfalls, such as the use of bank and agency staff, flexible working patterns and reviewing skill mix to create new roles to meet patient’s needs.

• Actual and planned staffing levels were clearly displayed across the trust and generally we found then actual levels were in accordance with the planned.

• Although agency staff were used, overall the trust used slightly less bank and agency staff than the national average. There was an induction process for agency staff to make sure they were familiar with their working environment.

• Recognised staffing assessment tools were used to assess the required numbers and skill mix of staff.

• There were some concerns expressed by staff in the children’s service that the assessment there was not robust. We did not observe any negative impact of the staffing levels within the service, but they did not meet suggested levels issued by the Royal College of Nursing. However, these levels are not mandatory but can be used as a guide.

Mortality Rates

• Patient outcomes were monitored across the trust. The Quality and Audit Committee reviewed patient outcome data and this was then reported to the trust board. Each directorate also reviewed their speciality specific outcome data. Many of the patient outcome metrics were in line with or were better than the England average. Where they were worse, improvements had been identified and action plans were in progress.

• The Summary Hospital-level Mortality Indicator (SHMI) is an indicator which reports on mortality 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 on the basis of average England figures, given the characteristics of the patients treated there. The trust wide Standardised Hospital Mortality Index (SHMI) was 103.01between August 2014 and July 2015. This meant the SHMI score was higher than expected for the trust.

We saw several areas of outstanding practice including:

• The Department for Research and Education in Emergency Medicine, Acute medicine and major trauma (DREEAM) provided all training for the emergency department. There was a focus on an inter-professional approach to education ensuring all staff groups learnt with, from and about each other. Clinical educators included a consultant, teaching fellows, an emergency nurse practitioner, an advanced nurse practitioner and nurses from nursing bands two to eight. All staff worked clinical shifts in the emergency department. Staff were passionate about learning and without exception they told us education in the emergency department was excellent.

• Trained volunteer simulated patients took part in clinical training. These ‘patients’ were able to give feedback to staff about how it felt to be their patient. Their feedback included views values and behaviours so staff could develop their approach to patients as well as their clinical skills.

• The initial assessment unit (IAU) in the adult emergency department. There was an initial assessment unit (IAU) operating in the adult emergency department 24 hours a day, seven days a week. All patients arriving by ambulance, except those going straight to the resuscitation area were seen in the IAU. All patients arriving independently and assessed as having a major injury or illness were also sent to the IAU by streaming nurses. Nurse led investigations took place immediately and an advanced nurse practitioner (ANP) or middle grade doctor was available in the area between 10am and 2am to support decisions. The introduction of the IAU had improved initial assessment times for patients. Data provided by the trust showed initial time to assessment was consistently better than the 15 minutes standard from January 2015.It also meant that once patients saw a doctor all the necessary information was available to make a diagnosis and treatment plan.

• The role of trauma case manager. This senior nurse would attend the emergency department and act as scribe for the call. They would introduce themselves to the family and patient on arrival at hospital and would remain their main point of contact for the duration of the patient’s stay there. When a patient was discharged the case manager gave them a business card with their contact number so if they had any concerns they could telephone for advice.

• The Injury Minimisation Programme for schools in the children’s emergency department. The trust was delivering an Injury Minimisation Programme for Schools (IMPS) in partnership with schools and a public health organisation. The programme was designed with the aim of educating children aged 10 and 11 to recognise potentially dangerous situations and prevent injuries. Small groups of children from Nottingham city schools attended the children’s emergency department each morning to learn first aid and resuscitation skills, helping them to respond effectively to accidents and take safe risks. More than 2,300 children received health education through this programme each year.

• The ethos of education within the emergency department.

• Trials of GP led front door. During 2014 the trust piloted having GPs at the front door of A&E on two separate peak activity weekends. As a result, patients seen by a GP spent 50 minutes less in the department. There was also a reduction in patients needing to be seen by the minor illness and injury teams. The findings showed 54% of patients were redirected away from A&E to more appropriate services with the majority being directly discharged home.

• Newly qualified or appointed nursing staff wore orange lanyards so they were easily recognised by other staff who could offer them extra support in the emergency department.

• An occupational therapist on ward F20 had undertaken a six month pilot project called ‘Playlist for life’. The project involved asking patients about songs that were personal to them and they would like to listen to. Where patients were unable to list songs that were personal to them, their family or carers were encouraged to create a playlist on the patients behalf. The playlists were then created on MP3 players and provided to patients free of charge. An observation tool was created to monitor patient’s mood, engagement, responses and communication pre, during and post listening to their playlists. Twelve patients took part in the pilot and the results were then analysed and found to be overwhelmingly positive. At the time of our inspection a meeting was taking place to discuss how the experience could be continued throughout the ward.

• With the support of nursing staff, a consultant on ward F20 had started an ice cream project in order to support patients who were nutritionally at risk. A business case was submitted and supported by the League of Friends for funding to buy a freezer and a supply of high quality, high calorie ice cream. Patients who were nutritionally at risk had an ice cream sign placed on the board above their bed and this prompted staff to ensure these patients were supported to eat ice cream. The project had come to an end and the consultant was working on applying for more funding to continue the ice cream project.

• Patients wore a coloured wrist band to highlight the oxygen rate they were receiving. This ensured staff could easily identify the patient’s required rate and ensure they were receiving safe care.

• On ward B47 we saw there was an activities board which detailed activities available for patients each day of the week. We observed activities taking place which were led by a physiotherapist and a health care assistant. We saw patients enjoying diversional therapy in the ward’s day room. There was music playing and they were reminiscing about the seaside. They talked about holidays and swimming in the sea and we heard them singing seaside songs. We also saw patients having a tea party, drinking tea from china cups. There were tissues on the table if patients got upset whilst reminiscing. A Pets as Therapy (PaT) dog visited the patients on this ward. We saw that patients enjoyed this and were smiling as the visit took place. We saw these activities had a positive effect on patient’s well-being.

• At the Breast Institute, patient escorts met and greeted patients and showed them through the building to the right place. They showed patients where the changing rooms and lockers were, would fetch what they needed and tried to put them at their ease. The Breast Institute also had ‘Caring around the Clock ‘- a nurse visited the patient hourly to communicate between them and the surgery.

• Admissions managers in cardiac services offered emotional support to patients. They dealt with planned and emergency patients. The manager contacted the planned surgery patients promptly and informed that about what to expect, and dealt with any anxieties. For emergency patients, the admissions manager took all the details and arranged the admission with the appropriate consultant, streamlining the process and resulting in prompt service. Feedback on the ward’s wall showed that patients appreciated this approach.

• Staff offered acupuncture to patients to relieve post-operative nausea and vomiting. This was based on research studies that showed acupuncture to be at least as good as anti-sickness medication.

• Theatre staff initiated the ‘Think Drink’ project in response to feedback from patients who felt dehydrated whilst waiting for their operation. The project resulted in new guidance for staff to identify which patients could have a drink up to two hours before their operation.

• Theatre staff had successfully standardised practices and processes at QMC and Nottingham City Hospital to ensure safe ways of working and reduce cultural differences. The theatres safety improvement programme implemented a variety of safety projects. It ensured that all theatre staff were trained on team etiquette. This emphasised safety, mutual respect, effective communication, accountability and situational awareness. As a result, theatres ran more safely and efficiently.

• The creation of the Safer Surgery Group had led to improved reporting of incidents, a more open culture, increased productivity and a reduction in serious incidents. There was an effective network of theatre patient safety leads and champions. The theatre patient safety leads had presented their work at an international conference in 2015.

• Adult Critical Care demonstrated outstanding knowledge of safeguarding and MCA and were able to explain its purpose and application in the critical care setting.

• The use of an innovative new pregnancy phone application (pocket midwife) assisted in the information given to women. The phone ‘app’ consisted of general pregnancy information that was useful to all prospective parents and their families. It also contained information specific to the trust, such the trust's own maternity leaflets and useful contact telephone numbers.

• The shared governance council was very active in maternity services. Staff of all grades volunteered for a term and promoted their ideas to gain funding. For example, staff on the ward carried out an audit of time it took to keep refilling water jugs. Staff presented the audit to the executive team and were granted funding for a self-service water coolant. Staff were extremely proud of this project.

• There were excellent personal and professional development opportunities for staff, and many departments were active in research.

• The use of technology across the trust was outstanding. There was a strong vision for ICT services with excellent clinical engagement.

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

Importantly, the trust must:

• The trust must take action to ensure that nursing staff working in the eye casualty receive training in the recognition and treatment of sick children.
• In surgical services the trust should take action to ensure that the principles of the Mental Capacity Act 2005 are correctly and consistently applied in assessing the capacity of patients to make specific decisions
• The trust must ensure 50% of nursing staff within critical care have completed the post registration critical care module. This is a minimum requirement as stated within the Core Standards for Intensive Care Units.
• The trust must ensure midwives have appropriate training to provide safe care for high dependency women in an appropriate environment.
• The trust must ensure midwives have the appropriate competence and skills to provide the required care and treatment to women who are recovering from a general or local anaesthetic.
• The trust must be consistent in the documentation of checking of emergency equipment and ensure that the resuscitation trolleys, neonatal transport systems and resuscitation equipment are checked, properly maintained and fit for purpose in all clinical areas.

• The trust must take action to ensure Do Not Attempt Cardio-Respiratory Resuscitation decisions are documented legibly and fully in accordance with the trust’s policy and the legal framework of the Mental Capacity Act 2005.

Professor Sir Mike Richards

Chief Inspector of Hospitals