Buckinghamshire Healthcare NHS Trust

Updated 4 July 2022

We carried out this unannounced inspection of two services at each of the acute hospitals provided by this trust. The inspection was in response to information we hold about the trust and as part of our risk based inspection schedule. We did not inspect any community services on this occasion, although the historic ratings from previous inspections counted towards the overall ratings.

We also inspected the well-led key question for the trust overall.

We inspected the surgical services and the medical services at both Stoke Mandeville Hospital and Wycombe hospital. We did not inspect community health inpatient services.

We rated effective, responsive and well led as good, caring as outstanding and safe as requires improvement.

In rating the trust, we considered the current ratings of the 15 services that we did not inspect this time.

Our rating of services remained the same. We rated them as good because:

• Staffing levels were carefully monitored, and steps taken to maintain safe staffing levels. Although at times staff felt stretched. Staff understood how to protect patients from abuse. Medicines were managed well, in general. The trust managed safety incidents well and learned lessons from them.
• Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service. Staff worked well together for the benefit of patients and supported them to make decisions about their care. Key services were available seven days a week
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback.
• In most areas’ leaders were visible and approachable and staff were supported to develop their skills. Staff understood the trusts vision and values. In general staff felt respected, supported and valued. The trust promoted equality and diversity in daily work and provided opportunities for career development. The trust engaged well with patients and the community to plan and manage services and staff were committed to improving services continually. There were established governance systems with clear reporting lines from the ward and units to the trust board. The trust collected data and analysed it. Data was used to understand performance and make decisions.
• The trust had worked to maintain some of their elective services during the COVID 19 pandemic and recovery plans were being implemented to ensure that the backlog was addressed.

However,

• Staff adherence to infection control guidance was variable.
• Staff were not always supported to develop through yearly, constructive appraisals of their work.
• Engagement in and understanding of quality improvement was variable. • Training in working with people living with dementia and those with learning disabilities was not mandated.
• Substances that were subject to COSHH regulations were not always managed safely.

How we carried out the inspection

• We reviewed 68 patient records.
• We spoke with 129 members of staff,
• We spoke with 40 patients and three carers.
• We visited 25 wards and units including the operating departments.
• We attended one site meeting and one senior nurse’s safety meeting.
• We observed interactions between staff and between staff and patients.
• We looked at information such as staffing number and rotas, staff training, and bed management. We looked at medicine’s management, checked equipment, medical devices and consumables.
• We reviewed information provided by the service following the inspection.

You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/ how-we-do-our-job/what-we-do-inspection.

What people who use the service say

Patients were complimentary about the care they received and felt they were treated with respect and kindness. There was a general recognition staff were busy and at times appeared to be short of staff, which meant sometimes patients waited a little longer than they would have liked but did get the help they needed.

The Inspection team

The team responsible for inspecting and reporting comprised two inspection managers, CQC inspectors and specialist advisors. The inspection was overseen by Amanda Williams, Head of Hospital Inspection.

Updated 18 June 2019

Updated 18 June 2019

Updated 18 June 2019

Our rating of this service improved. We rated it as good because:

• The service provided mandatory training in key skills to all staff, and staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staffing levels and skill mix were planned and reviewed to ensure patients received safe care and treatment.
• The service controlled infection risk well. Staff kept themselves, equipment and the premises clean, and kept appropriate records of patients’ care and treatment.
• Risk assessments were carried out for people and risk management plans were developed which ensured staff delivered safe care and treatment.
• Patients received the right medication at the right dose at the right time. There were processes to ensure care and treatment was delivered in line with current evidence-based national guidance.
• The service used safety monitoring results well. Staff collected safety information and shared it with staff.
• Staff assessed patients’ nutrition and hydration needs using appropriate assessments, where applicable and managed patient’s pain effectively.
• The service ensured staff were competent for their roles and had access to up-to-date, accurate and comprehensive information on patients’ care and treatment.
• Staff in different professional groups, including local GPs, worked together as a team to benefit patients, and patients were given advice on improving their general health and wellbeing.
• Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• Staff treated patients with compassion and provided emotional support to patients to minimise their distress. Patients and those close to them felt involved in decisions made about their care and treatment.
• The service planned and provided services in a way that met the needs of local people ensuring patients had flexibility and choice. In all areas we saw that staff tailored their services in response to the complex needs of vulnerable patients.
• The service had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care. They promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
• The service used a systematic approach to continually improve the quality of its services and safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish.
• There were effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.
• The service engaged with patients, staff, the public and local organisations to plan and manage the delivery of care in the community and collaborated with partner organisations effectively.
• The trust was committed to improving services by learning from when things go well and when they go wrong.

However:

• The trust did not include responding to the deteriorating patient as part of their mandatory training programme.
• Not all teams were able to complete staff appraisals within the trust timescales.
• Complaints received were not dealt with according to the trust complaints policy

Updated 18 June 2019

Our rating of this service improved. We rated it as good because:

• Children, young people and families were protected from poor care and abuse by staff who had the relevant skills and received appropriate support. This was by mandatory training, safeguarding awareness, competency assessments, supervision and appraisals. Where there were staff shortages the service took actions to reduce the level of risk to patients.
• The service had a culture of learning from where things had gone wrong, this included learning from incidents and complaints.
• The service mostly provided care and treatment based on national guidance. Staff followed processes to ensure management of medicines was carried out in a sure way that met national guidance.
• There was effective multidisciplinary working both across the trust and with partner organisations.
• The leadership of the service supported monitoring and improvements to the services they delivered. The service engaged well with patients, partner organisations and staff. Staff reported a supportive working environment that looked after their wellbeing as well as supporting them in their personal career development.

However,

• Health visiting performance was below the national average. Health visiting and some aspects of the Looked after Children’s performance did not meet national targets. People could not always access services in a timely manner. Waiting times from referral to treatment were not in line with good practice.
• Although the service had systems for identifying risks, not all risks were formally identified which meant there was no plan to eliminate or reduce them.
• Although the service collected information, not all information was analysed and used to support all its activities.

Updated 18 June 2019

Our rating of this service stayed the same. We rated it as requires improvement because:

• Buckinghamshire Community Hospital’s environment did not support patients to move independently within the ward. Staff documented risks and deterioration to patient’s health, however these records were not always accurate, and we could not see appropriate action was always taken in response to an identified patient decline. The service was not sufficiently staffed to meet patient needs which impacted on patient therapy and hospital length of stay. Documentation relating to medicines storage did not always meet best practice guidelines.
• Systems in place to recognise, document and escalation risks relating to governance, quality and performance were not effective in identifying key risks to service delivery. Previously identified staffing concerns for inpatient services had not been fully addressed and impacted on patient care.

However:

• Most staff had received up-to-date mandatory training, including safeguarding. Premises and equipment were visibly clean and available for patient use. Medicines were managed safely. The service monitored key safety performance and incidents were reported and investigated.
• Patients received effective care and treatment which met their needs. The trust participated in benchmarking programmes to drive improvements to the service. Staff development was encouraged, and appraisals were up to date. Patient’s received care from integrated multidisciplinary care teams. Patients were supported to make decisions about their care.
• People were supported, treated with dignity and respect, and were involved as partners in their care. Patient feedback results were good, and most patients we spoke with were happy with their care. Staff were compassionate and helpful in their interactions with patients.
• Patient needs were met through the way services were organised and delivered which included those in vulnerable circumstances. Patient complaints were investigated, and responses provided.
• The leadership, service vision and culture sought to promote the delivery of high-quality person-centred care. Teams felt supported by managers and were supportive of each other. Staff and patient engagement was sought and innovation encouraged.

Updated 10 July 2015

Overall this core service was rated as ‘good’. We rated community end of life care as ‘good’ for providing a safe, effective, caring, responsive and well led services.

Our key findings

Are services safe?

• Incidents were reported and there was evidence of learning and improvement as a result. Safeguarding procedures were understood.
• Patients were supported to understand the medication they were taking and how this could be best used to control their symptoms.
• Medicines to support patients at the end of life were available in the community. Patients had the equipment they required to support their care safely in their own home.
• Staff followed good infection control procedures.
• There were sufficient specialist staff to support patient.
• Staff used records appropriately and were well informed about the potential risks for patients and how these were to be managed.
• Do not attempt cardio-pulmonary resuscitation (DNA CPR) forms were being used and this was monitored through audit.

Are services effective?

• In line with national recommendation the Liverpool Care Pathway was no longer being used and the trust had developed a new pathway that was about to be trialled. Consideration was being given to the Priorities for Care of the Dying Person set out by the Leadership Alliance for the Care of Dying People.
• New treatment escalation plans had also been developed in line with national guidance. Patient’s pain was well managed and the clinical nurse specialist (CNSs) worked in partnership with patients to ensure that this was achieved.
• Patients nutrition needs were discussed and reviewed by the CNS as part of their holistic approach.
• The trust had participated in the 2013/14 National Care of the Dying Audit – Hospitals (NCDAH) and did not achieve five of their seven key performance indicators (KPI’s) but was similar to the England average for most of the clinical indicators. Local audit to monitor the effectiveness of services was not well developed. The trust had acknowledged this gap and audit needed to be introduced.
• Training in end of life care was available to all staff and specialist staff was further supported to develop their skills. A
• There was a single point of access for all referrals for specialist palliative care and anyone, including parents, could refer a child to the children’s palliative care team.
• Staff worked together to provide a multidisciplinary service and GP services to provide holistic care and prevent emergency admissions.
• Staff had the information they required to care for patients and were conscious and informed about the requirement to seek consent.

Are services caring?

• Staff demonstrated a caring and compassionate approach.
• Patients and their families were positive about the care and support they received and the way they were treated.
• Staff were courteous and treated patients and their families with dignity and respect. Patients and their families were involved and encouraged to be partners in their care and in making decisions.
• People and staff work together to plan care and there is shared decision-making about care The CNSs provided emotional support and would refer patients to other professionals if additional support was required.

Are services responsive?

• The trust had developed an action plan to improve its end of life service and a project lead had been employed to move this forward. The trust had engaged with staff, patients and their relatives as part of this project.
• The CNSs took a holistic approach to their role and the service was available to all.
• The children’s hospice at-home team offered individually tailored care, adapted to the child and family’s needs.
• An interpreting service was available although family members often acted as interpreter.
• The CNS managed their own diaries to ensure that patients were visited at time suitable for them. The children’s palliative care team worked in a similar way liaising with families and scheduling support at a time that would best meet their needs.
• Support and advice was available 24 hours a day and staff were clear on how to access this support.
• The community teams worked together to support patients and their families and to ensure that they had the support and equipment they required.

Is the service well led?

• There was a clear vision for the service and the end of life care strategy was being reviewed to ensure that it reflected the service as a whole.
• The trust was actively making changes to the service to ensure it better reflected current guidance, although while there was some monitoring of the quality of the service, this required further development to include audit and the monitoring of outcomes for patients.
• The director of nursing was the lead for the service at board level and had clear insight into the challenges they were facing and the changes being made.
• At a local level there was respect for the lead consultant in palliative care.
• The matron’s role had been expanded and their responsibilities increased, and they were receiving support with their development to assist them in their role.
• There was an open culture that placed the patient and their family at the centre.
• There was a team approach to caring for patients in the community, with joint working between specialist staff, the adult community healthcare team and the community hospitals.

Professor Sir Mike Richards

Chief Inspector of Hospitals