Burnley General Hospital is one of seven hospitals and care centres that form East Lancashire Hospitals NHS Trust. It specialises in planned (elective) treatment and has 291 beds. The hospital includes an Urgent Care Centre (UCC) for treatment of minor injuries and illnesses. It does not include an Accident and Emergency (A&E) department or supporting facilities such as intensive care. These services are provided from the Royal Blackburn Hospital.

We carried out a comprehensive inspection because East Lancashire Hospitals NHS Trust had been flagged as high-risk on the Care Quality Commission (CQC) intelligent monitoring system which looks at a wide range of data, including patient and staff surveys, hospital performance information, and the views of the public and local partner organisations. The inspection took place on 30 April, 1 and 2 May 2014.

Overall, Burnley General Hospital requires improvement. We rated it as ‘good’ for caring for patients and providing effective care. It requires improvement in providing safe care, being responsive to patients’ needs and for being well-led.

Our key findings were as follows:

• Staff were caring, compassionate and respectful and maintained patients’ privacy and dignity.
• The hospital was clean and well maintained. Staff were seen to be adhering to the “bare below the elbow” policy, washing their hands regularly, and hand gel was readily available. Infection control rates were similar to that of other hospitals.
• Some patients did not understand the purpose of the UCC. This meant that sometimes patients who attended the department did so inappropriately and required transfer to a centre that was fully equipped and staffed to meet their needs. Sometimes transfers were not responsive enough which could delay treatment and put patients at risk.
• The trust had undertaken much work to improve its mortality rate — currently slightly above the expected range.
• Performance against access target in the Urgent Care Centre was consistently good, however, some patients who required mental health assessment or admission to a specialist service waited too long in the department which was not resourced to meet their needs.
• Care on the medical wards was safe, effective, caring, responsive and well-led. Staffing levels in the wards had improved over the last 12 months, however, there remained some vacancies for qualified staff.
• Patients’ nutritional needs were appropriately assessed and a suitable diet provided. Although not unanimous, the majority of patients said the food was good.
• Surgery was effective but the routine checking of theatre equipment lists was not undertaken which posed a risk to patients.
• Theatres were not utilised to their full capacity, with a number of empty lists every week.
• Patient privacy and dignity was at risk of being compromised as male and female patients, as well as children, were all waiting together in the theatre reception area.
• Maternity services provided safe and effective care. Maternity services had improved the normal birth rates, reduced caesarean section rates and increased birthing choices for women; they had received an award for this.
• Surgery was effective but the routine checking of theatre equipment lists was not undertaken which posed a risk to patients.
• Care for children and young people was safe, effective, caring, responsive and well-led.
• Patients received safe and effective care end of life care from ward staff and a specialist palliative care team. However, this specialist care team was only available Monday to Friday from 9am to 5pm. Outside of these hours, support was provided from the local hospice.
• There was a limited bereavement service available. The trust recognised this and was aiming to recruit to this service.
• A new strategy for end of life care had been drafted. At the time of the inspection, this had yet to be approved and therefore new ways of working were not yet embedded into practice.
• Patients in outpatients were treated with dignity and respect by caring staff who worked to maintain their safety. However, clinics were sometimes cancelled at short notice and frequently ran late.
• Patients attending outpatients expressed difficulties with the car parking arrangements. The demand for spaces was high and often resulted in a long walk to the appropriate clinic.
• Staff were very positive about the current leadership of the trust. They felt the culture was more open and honest and felt supported in raising concerns and reporting incidents.

We saw several areas of outstanding practice including:

• East Lancashire Hospitals NHS Trust’s maternity services were awarded the Royal College of Midwives’ Mothercare Maternity Service of the Year award for their ‘innovative work to improve maternity services, promote normal births and facilitate staff engagement activities’. The award also recognised their work in reducing caesarean section rates and increasing birth choices for women.
• The breast and gynaecology ward was very well designed. The early pregnancy unit, ultrasound scanning suite and gynaecology theatres were all in close proximity and purpose-built, with staff having input into the planning of the building. This created an outstanding setting to facilitate a responsive service for outpatients visiting the early pregnancy unit and inpatients staying on the ward. For example, patients were actively encouraged to attend the assessment area if they experienced any post-operative complications so they could be seen by a gynaecologist quickly rather than having to attend A&E at Royal Blackburn Hospital.

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

Importantly, the trust must:

• Ensure that there are always sufficient numbers of suitably qualified, skilled and experienced staff employed in the Urgent Care Centre (UCC) at all times to care for very unwell children.
• Ensure that acutely unwell patients who attend the UCC, and require emergency or urgent transfer to the Royal Blackburn Hospital or other centres, receive the appropriate response.
• Ensure that people who attend urgent care with mental health needs receive prompt, effective, personalised support from appropriately trained staff to meet their needs.
• Ensure that there is an appropriately resourced bereavement service available.
• Take action to prevent the cancellation of outpatient clinics at short notice and ensure that clinics run to time.
• Ensure that instruments are checked and accounted for before and after each procedure and that there is documentary evidence to support this.

In addition the trust should:

• Consider improving the management of theatre activity to increase patient flow.
• Review the layout of the theatre reception area to maintain the privacy and dignity of all patients.
• Take action to finalise the strategy for end of life care and ensure this is embedded in practice.
• Consider the appropriateness of the lack of lifting equipment should a person fall or collapse and be unable to lift themselves in the UCC.
• Work to improve the number of staff in the UCC attending mandatory training.
• Assess the frequency of the review of local risk registers.

Professor Sir Mike Richards

Chief Inspector of Hospitals

We spoke with five patients on ward 10 of the Lancashire Women’s and Newborn Centre, all had recently given birth in the birthing suite. We also spoke with midwives and senior managers and looked at a sample of records and policies and procedures.

All patients spoken with made positive comments about their care and support throughout their pregnancy and in particular during the birth of their baby. One patient told us, “The consultant and midwife were both brilliant and very supportive”. Patients were closely involved in decisions about their care and that of their baby. Each person had an individual midwifery care plan which was reviewed following any change of need or circumstance.

Midwives had a thorough understanding of safeguarding procedures for the protection of children and vulnerable adults. We saw evidence to demonstrate that midwives worked in collaboration with other agencies such as the Police and Social Services to ensure a coordinated response to safeguarding issues.

Midwives had access to appropriate supervision and were given opportunities to update and extend their training in line with their roles. We saw records of staff training during our visit.

There were established and effective systems in place to monitor the quality and safety of the service which included the analysis of patient feedback. We saw examples of how these systems worked together to monitor the performance of the Trust.

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

• Staff across the hospital had completed mandatory training in key skills and understood how to protect vulnerable patients from abuse and how and when to report incidents.
• The hospital and equipment were suitable for the services provided and were clean and tidy. With few exceptions, staff followed infection control measures.
• Staff completed risk assessments for patients and kept a good record of the care and treatment patients were receiving.
• There were sufficient nursing, medical and other staffing to keep patients safe. While there were sufficient staff, the urgent care centre was reliant on locum doctors and nurses on medical wards were moved between areas when there were staffing gaps.
• Services at the hospital delivered care in line with national guidelines and best practice. Services were participating in local and national audits to improve practice. Patients had good outcomes from their treatment.
• Patients received food, drink and pain relief when they needed it. Staff had training and understood what to do if someone lacked capacity or experience mental ill health.
• Staff received the right training for their roles and in medical care and surgery had annual appraisals. In urgent and emergency care the rates of appraisals was lower than the trust target. Staff worked well together and worked well with staff and services outside of the hospital.
• Staff throughout the hospital were kind, compassionate and caring to patients, their carers and family members. Patients were involved in decisions about their care and given emotional support.
• Services were planned to meet the needs of people using the hospital and services were responsive to the individual needs of patients.
• The hospital had managers with the right skills and abilities to lead the services. There was a positive culture and morale was generally good throughout the hospital.
• The services in the hospital had effective governance structures and systems to manage and act on risks and performance issues. The services were committed to improving services and used information and engaged with staff and the public to improve services.

However,

• While patients received the right medicines, at the right doses, at the right time, the hospital was not always following best practice for the storage of medicines and the process for patient group directions was not robust.
• Some equipment was not checked or serviced as frequently as it needed to be to ensure staff that it was safe and ready to use.
• In the Rakehead rehabilitation centre patients did not receive a seven-day service as there was limited therapy support at the weekends.