Our rating of services remained the same. We rated it them as requires improvement because:

• The rating requires improvement was given because although all of the services we inspected in March 2018 had shown significant improvements, the rating is aggregated with the ratings from previous inspections which continue to be considered where we have not re-inspected.
• Staffing continued to be a challenge. There were innovative roles created to mitigate some of the risks, there was ongoing recruitment and there was better use of in-house bank staff over agency staff. The only area where we saw an unacceptable impact was with the administrative and reception staff in the emergency department who felt unable to have any breaks during long shifts.

However:

• We were aware from our ongoing monitoring of wider improvement in core services which were not inspected in March 2018. These improvements cannot be reflected in the ratings as they have not been corroborated trough inspection.
• The ongoing monitoring and information we hold about Conquest Hospital, coupled with discussions with numerous staff, showed a cultural shift which resulted in a more motivated workforce and a commitment to improving the quality and safety of services. This was true across all areas of the hospital whether inspected at this inspection visit or not.
• Incident reporting and learning from incidents was embedded in everyday practice. Monitoring and reviewing activity enabled staff to understand risks and gave a clear and current picture of performance and safety. The number of incidents reported had increased steadily since our inspection in October 2015 but the number of incidents resulting in harm had fallen. This demonstrated a good reporting culture.
• Never events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. Each never event type has the potential to cause serious patient harm or death but neither need have happened for an incident to be a never event. From December 2016 to November 2017, the trust reported three incidents classified as never events. The trust had provided a robust response to all incidents to reduce the risk of recurrence.
• Staff took a proactive approach to safeguarding and focussed on early identification and intervention. Staff from the Conquest Hospital were actively engaged in the local safeguarding arena and with other providers. Staff were trained to the appropriate level.
• Risks to patients were assessed, monitored and managed on a day-to-day basis. This included observing for signs of deteriorating health, medical emergencies and challenging behaviours.
• Peoples care and treatment was planned and delivered in line with current national guidance and legislation. There was ongoing monitoring to ensure that practice and policy remained in line with best practice guidance.
• People had comprehensive assessments of their needs with consideration of their clinical needs, mental health and nutritional needs. Data provided showed improvements in assessing individual risks such as for venous thromboembolism (VTE). There was also a steady decrease in the incidence of falls with harm resulting from improved risk assessments.
• There was good multidisciplinary working across services.
• Consent was obtained in line with the current legislation and guidance including the Mental Capacity Act 2005, and the Children Acts 1989 and 2004. People were supported to make decisions and where appropriate their capacity to consent was assessed and recorded.
• Infection prevention and control practice was much improved and there was data available to demonstrate that the hospital was routinely cleaned to an acceptable level in line with the National Specification for Cleanliness in the NHS.
• There was a very person centred culture that had developed since our previous inspection in October 2015. Staff wanted to provide good care and were kind and compassionate in their interactions with patients. This was reflected in the results from the Friends and Family Test.
• On previous inspection visit in October 2015 some staff were unclear about their line management arrangements and felt unable to raise concerns. There were several complaints to the inspection team about bullying. This had now changed. Staff reported approachable and supportive managers, clear lines of accountability and an executive and senior management team who were visible and who listened to frontline staff.
• The governance processes were robust and understood by all. Work had been done to streamline the Risk and Quality Delivery Strategy that made explicit the lines of accountability and reporting systems. There was effective information sharing in both directions between the frontline operations and the board.
• In medicine for the referral to treatment time (percentage within 18 weeks) - admitted performance. The performance of the trust was consistently better than the England average from December 2016 to November 2017.
• The length of stay and waiting lists were in line with national standards and comparators

On the 7 May 2013 the East Sussex Healthcare NHS Trust (ESHT) completed a temporary reconfiguration of maternity and paediatric services. This had been undertaken as a result of an escalation in concerns regarding the overall safety of Maternity provision within the acute hospitals.

The Care Quality Commission made plans to review the newly configured service, and allowed a month for the new service arrangements to embed. Prior to our planned visit we received information from a team of consultant paediatricians working at Eastbourne District General Hospital. They expressed concerns about the new arrangements for paediatrics across the Trust. We met with the consultants on 18 June 2013 supported by a paediatric specialist. We listened to their concerns and gave these due consideration in our planned inspection of these services.

When we visited the services at the Conquest we were supported by a paediatric specialist, and a maternity specialist. We spoke with staff at all levels of the Trust to gain their views about the safety of the service. We looked at systems, and reviewed documentation. We spoke with parents, mothers and relatives of people using these services. From the feedback we received and records viewed we were satisfied that the Trust was providing a safe, effective, responsive, caring and well led maternity and paediatric service.

We spoke to people using the service (patients), relatives, and staff in all of the areas we visited.

Patients told us that they felt their privacy and dignity was respected, that staff ensured curtains were closed during personal care and treatment.

We were told that patients were involved in their care and treatment. One patient told us “When I ask about my condition I get an honest answer”. Another told us “Staff are so thoughtful and kind, you can’t fault them” and another told us “I choose to get up and dressed every day”. A visiting carer told us that staff were aware of the communication tools to use with a patient with learning disabilities.

Staff told us they had received training in privacy and dignity and in respecting choices. An occupational therapist told us that they ensure patients are covered in a dressing gown when they go for therapy.

Patients told us that staff were polite to them and that they felt safe in the hospital.

Overall most patients were very complimentary about their care and treatment throughout their hospital stay.

We visited Maternity, MacDonald, Egerton, Benson, Cookson Devas and Wellington wards. The majority of patients we spoke with told us that they felt well informed about their care and treatment and had been involved in decision making around this.

Patients said that medical and nursing staff were actively maintaining their privacy and dignity by pulling curtains and in some instances using clips to further improve privacy.

Overall patients told us that the care they had received had been good and that staff had a good understanding of their needs.

Most patients spoken with thought that the general standard of cleanliness was good.

However on MacDonald ward two patients spoken with said that they had not been appropriately supported.

The patients that were able to speak with us told us that they were satisfied with the care and treatment they received at the Conquest Hospital. Four relatives also told us they were happy with the care their relative was receiving. They stated they had been treated with courtesy and respect and that their privacy and dignity had been well-protected.

“Very good staff, always polite and so very helpful” “Nice staff, the doctors are very polite and they keep me well informed of my test results and treatment” “Very good, speak to me as if I mattered”

”The ward is wonderful, could not be cared for any better” “I feel that sometimes I could be taken to the bathroom, I feel a little embarrassed using a commode in the ward”.

Some patients said that hospital staff provided advice and information to people about their health needs and the management of their condition. Two patients said “Helpful and kind” “Information is given, but I have to ask “.

We were told by patients that staff had asked them what they wanted to be called on their admission to hospital and that this was respected throughout their stay.

However, people also told us that their preferences were not always asked for or taken into account such as having a choice of male or female staff for personal care.

People we spoke with gave us mixed feedback about the mealtimes, food and nutrition provided during their stay in hospital.

Positive comments included that the food is much better than it used to be, and that there is a good choice. One person said, “Always something I fancy” Other comments included, “I enjoyed the food, I am never hungry and there is always enough to eat”.

Some of the people told us that the meals look alright but is lacking in taste, mainly due to being slightly dry. Other comments were that there is limited choice for special dietary needs and that the main meal and a hot dessert are given at the same time so the dessert has to be eaten cold. One patient told us the food “Tasted horrible”, because she was given her medication at the same time. Another said “I don’t like the food so I don’t eat it”.

We spoke to people using the services and staff in each of the areas that we visited.

People who use the maternity service said they were able to decide what care and support they would have. Women told us that they know what is in the care plans, they agreed with the information in them before coming into hospital, and the staff were ‘very good’ and they are ‘very happy with the support from the staff’ who are available if they need anything.

People thought that the maternity department was generally clean and they did not have any concerns. Some comments were made that the toilets were not particularly clean at the end of the day. Users of the services stated that staff were regularly seen to wash their hands.

The people spoken with in A&E who were able to express a view of the care were very positive about the treatment they received. They felt the staff were professional and attentive. People were satisfied with the care that they received while a patient in the Accident and Emergency department. They felt that the staff were attentive and responded to their needs in a timely manner.

Two people spoken with on the wards generally felt that they were looked after well. With comments ranging from “can’t fault the staff” to “excellent care”. There were mixed views from patients, with some stating that they were awaiting further tests and were unclear as to when they would be carried out or why, while other patients felt well informed by medical staff about their condition and treatment and also felt listened to by staff.

Patients spoken with confirmed that their personal hygiene needs were being attended to, however one patient said that his wife had commented on his unshaven appearance and he had now received two shaves in a week.

One patient stated that they were very impressed with how their spiritual needs were being met and that they had three visits from local priests.

Other patients spoken with stated that overall they found the cleanliness to be good. Comments included: “High standard, cleaner will daily include all the loos and bathrooms”, “toilets all kept clean”, “staff are always hand washing between patients” “ the hand washing is almost excessive, but reassuring.”

One person said that staff respond to call bells quickly, others said “not immediately but any longer than five minutes”, “it depends what staff are doing, and sometimes it can take a while”. Another person said that they try to ensure that they call well in advance of needing staff so that they can allow for response time.

Only one of nine people spoken with on the wards said that they had looked at their individual care notes. Two people said that they didn’t think they were allowed to look at them. A number asked what was included in the folders. When asked if staff involved them when recording their notes everyone said no.

We inspected the Conquest Hospital as part of the East Sussex Healthcare NHS Trust inspection on 4,5 and 6 October 2016. The trust had been previously inspected in September 2014 and March 2015. On both inspections we identified serious concerns and gave the hospital an overall rating of inadequate. The trust was rated inadequate overall because the two location reports and the concerns that we identified across the trust relating to culture and governance. A Quality Summit which included all key stakeholder organisations was held in September 2015 and, following that meeting, I recommended that the trust be placed into ‘Special Measures’. This meant that the trust was subject to additional scrutiny and support from the local clinical commissioning groups and NHSI who provided an improvement director to advise and to monitor the implementation of action plans to address the shortcomings identified. The commission also maintained a heightened programme of engagement and monitoring of data and concerns raised directly with us.

This inspection was specifically designed to test the requirement for the continued application of special measures at the trust. Prior to inspection we risk assessed all services provided by the trust using national and local data and intelligence we received from a number of sources. That assessment led us to include six acute hospital services (emergency care, surgery, maternity and gynaecology, children and young people, end of life care and outpatients) in our inspection. The two other acute hospital services (medicine and critical care) and community services were not inspected as they had indicated good performance at previous inspections and our information review suggested that this had been sustained.

We did consider how medical services and the high number of medical patients impacted on patient flow and whether this affected other core services. We also visited medical wards as part of the review of end of life care.

We did not inspect community services as part of this inspection as they were currently rated ‘good’ overall. We did consider where new initiatives developed by the community services impacted upon the work of the two acute hospitals.

Following this inspection we have re-rated the services inspected. For other services we have maintained ratings from previous inspections. We have aggregated the ratings to provide an overall rating for the trust of requires improvement.Caring was rated as good, whilst safe, effective, responsive and well-led are all rated as requires improvement. This constitutes a significant improvement from the previous rating of inadequate.

.Our key findings were as follows: -

SAFE

• The incident reporting culture had been significantly improved.
• We saw clear evidence of learning from a Never Event with robust investigation and embedded changes to practice across the hospital.
• Staff understanding of duty of candour had improved.
• Infection control oversight had been significantly strengthened and hand hygiene practice was largely compliant.
• We were able to see fledgling improvements in the provision of services trustwide with clear indicators of positive changes from data provided by the trust and from national data we hold at CQC about the trust.
• Daily ‘Safety Huddles’ were being rolled out across the hospital. These encouraged the wider multidisciplinary team to share concerns and consider ways to improve the care of patients.
• Where compliance with VTE risk assessment and prevention had been a concern in our previous inspection report, there was now evidence of high rates of compliance with 95% of patients having a properly completed VTE risk assessment in July 2016.
• Safeguarding vulnerable adults and children was given sufficient priority.
• Medicines management processes had been significantly improved.
• The transfer of patients from ambulance to the emergency department was subject to delay and not being monitored.
• There was a significant backlog in the reporting of x-ray examinations.
• Record keeping was not consistent across the trust notably in the documentation of risk assessments within the emergency department and full completion of risk assessments in paediatric services.
• Where electronic recording and escalation of observations had been introduced this had demonstrably improved the outcomes for patients.
• Staff recruitment continued to be problematic with high levels of bank and agency use in some areas. There were departments such as the emergency department where the staffing arrangements were not in line with the national recommendations.

EFFECTIVE

• Pain was managed well with new initiatives in the care of children and young people and better recording of pain scores across the hospital.
• Stroke services had been consolidated at the Eastbourne site. A recent report issued by the Stroke Association in November 2016 showed that the hospital was providing good access to stroke services.
• End of life care and emergency departments were not meeting national audit standards in some areas.
• The assessment of mental capacity by staff remained inconsistent across the trust.
• The wishes of patients about the upper limit of treatment when on an end of life care pathway was not always recorded. Staff had not always discussed the 'ceiling of care with patients or their families.
• There were no services now rated as inadequate
• Policies were largely up to date and referenced by best practice, with the exception of maternity services.
•  Surgery services were no longer an outlier for clinical outcomes.
• Auditing programmes were more developed than on previous inspection visits but further work was needed to ensure that the full cycle of data collation being used to drive improvements needed further embedding.

RESPONSIVE

• The emergency department indicated a deteriorating performance against access standards.
• The trust was not maintaining the delivery of treatment to patients within 18 weeks of referral from GP's or within 62 days for patients referred onto a cancer pathway.
• Patient flow through the hospital was challenged leading to patients being cared for in suboptimal clinical areas.
• A Frailty Nurse Specialist team had been set up to work across the acute hospitals and community services to reduce the number of unnecessary admission (particularly from care homes) and to support patients who were best cared for in the community.
• Patients on an end of life care pathway did not have access to a rapid discharge service.
• The outpatients service was no longer rated as inadequate with significant improvements to the call centre.
• The hospital staff tried to ensure that the individual needs and preferences of patients were met. Our previous report from September 2014 talked about staffing shortages and a culture that led to task focussed nursing care and a lack of consideration of individual needs. This was not something we observed on this inspection visit.
• The trust was very responsive to meeting the complex needs of patients notably those living with dementia or learning disabilities.
• Appropriately trained staff were not available to support children who were particularly anxious or in pain through play
• Response times to complaints had improved significantly since April 2016. We saw evidence of appropriate responses to complaints, and learning from complaints and concerns. The trust had improved the way they responded to complaints as well as the response times.

WELL LED

•  No services were rated as inadequate for leadership.
• The senior leadership was now sighted on operational and strategic issues and had clear and well considered plans for service improvement.
• Staff told us that the executive team were much more visible around the hospital than they had been prior to the appointment of the new chair in January 2016 and new chief executive in April 2016.
• Nursing staff also talked to us about the Director of Nursing (DoN) who was felt to be a consistent and steadying influence as the trust went through a period of significant change. Nurses said they trusted the DoN and felt she was ever present, approachable and understood the challenges at ward level.
• The organisational culture had transformed since our last inspection. Staff were largely positive, well engaged and felt valued by the organisation. However, there were areas where staff were still feeling daunted by the changes and where morale was low. This was particularly the case with medical records and some administrative staff where the systems they worked with and, in some cases, their place of work had changed.
• Governance had been significantly strengthened in terms of structure and the quality of board papers and data.This had led to a strong sense of accountability within the trust.
• The senior team remains relatively new in constitution and some elements of governance and performance management have only recently been introduced
• The trust was yet to complete the transition to a new operational structure.
• At service levels our inspection identified some weaknesses in the management of risk and mortality.
• Innovation was now encouraged and we saw several areas where staff had been encouraged and supported to introduce changes to bring about improvements in quality and safety. Staff felt more engaged in developing the service and were allowed more involvement in how services were provided.

We saw several areas of outstanding practice including:

• Following the project lead midwife’s maternity review, the trust had introduced a programme of project groups related to maternity. These included the pilot scheme of a new homebirth and triage role for community midwives, and a perinatal mental health specialist midwife role.
• A consultant orthopaedic surgeon had written a national guide for the Royal College of Surgeons on avoiding unconscious bias which was published in August. The guide focused on overcoming the unconscious opinions that everyone forms about people when they first meet them and offered advice to get beyond this. This national guidance referenced the trust’s Anti-bullying Policy in the Doctors’ Clinical Handbook and highlighted the progress and work made within the trust to address perceptions of bullying and harassment.
• We saw an example of best practice for care provided to dental patients with special needs or learning disabilities.A multidisciplinary planning meeting was conducted in advance of the attendance. The appointment was used to provide one stop care including taking bloods, scans and giving the patient a haircut to minimise distress to the patient. There were a variety of options provided for location; aspects of care could be initiated in different locations such as properly supported sedation in the patient’s home and anaesthesia in the car park or in the hospital depending on the need.
• A dedicated multidisciplinary team had established a five-year plan to establish an innovative rehabilitation care plan as part of an out of hospitals services transformation programme. This programme included staff from multiple specialties and enabled ED staff to work with colleagues from across the trust and in the community to develop future services, including an ambulatory rehabilitation unit and a rapid access care service. The programme planned to introduce nurse practitioner roles for frailty, crisis response and proactive care who would provide an integrated rehabilitation service alongside hospital and community-based specialists. This programme would significantly improve working links between the trust’s hospitals and local authority social care services and enable rehabilitation services to be provided more responsively to avoid the need for hospital admissions. There was significant support and infrastructure for staff to develop this programme and they had been invited to present their plans and work so far at a national Health and Social Care Awards ceremony.
• Patients on a cancer pathway had a dedicated booking team in the booking centre. All referrals were received electronically and an email was sent to the GP to indicate it had been received. The booking team escalated concerns about appointments to service managers. Weekly cancer patient tracking list meetings provided clinical oversight of patients on cancer pathways.
• The paediatric team had introduced a ‘consultant of the week’ system whereby a designated consultant answered enquiries from local GPs about sick children in their care. This recent initiative had reduced the number of admissions because GPs had a specific point of contact and could be supported to care for the child in the community, where practical.
• An entrepreneur programme was being established that focused on the reduction of ambulance handover delays.
• There were good initiatives being developed and encouraged to meet people’s individual needs. The hospital’s League of Friends team had knitted comfort bands for patients, which helped them stop picking at intravenous lines. A ‘distraction box’ was also available to help provide stimulation for patients with dementia and reduce their anxiety in an unfamiliar environment. A nurse had developed a number of resources to help provide emotional support to parents who lost a child to sudden infant death syndrome.
•  A member of the maintenance team had given up his own time to paint a mural on the wall of the recently decorated ultrasound unit to soften the environment for young patients

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

Importantly, the trust must :

• Ensure that consultant cover meets the minimum requirements of 16 hours per day, as established by the Royal College of Emergency Medicine.

• Must develop play services in line with national best practice guidance.

In addition the trust should:

• The surgery directorate should  ensure completion of anaesthetic machine logbooks

• The surgery directorate should ensure compliance with: inadvertent perioperative hypothermia, NICE guidance clinical guideline CG 65.

• The surgery directorate should ensure accurate record keeping of controlled drugs in theatres.

• The surgery directorate should improve the quality, content and outcomes of mortality and morbidity meetings.

• The surgery directorate should ensure  compliance with the guidance contained in venous thromboembolism (VTE) in adults: reducing the risk in hospital QS3.

• The surgery directorate should ensure compliance with National Patient Safety Alerts regarding safer spinal and epidural needles.

• The surgery directorate should ensure a consistent governance structure across the two surgical directorates.

• Review all maternity policies and procedures that are outside their review date and take action to ensure all policies reflect current national and evidence-based guidance.

• The hospital should discuss and record ceilings of care for patients who have a DNACPR.

• The trust should have a defined regular audit programme for the end of life care service.

• The trust should record evidence of discussion of an end of life care patient’s spiritual needs.

• The trust should implement a formal feedback process to capture bereaved relatives views of delivery of care.

• The trust should ensure that all staff received regular mandatory training for end of life care.

• The trust should provide a formal referral criterion for the specialist care team for staff to follow.

• The trust should define and streamline their end of life care service to ensure staff are clear of their roles and who to contact.

• Develop a rapid discharge process for end of life care patients to be discharged to their preferred place of death.

  Extend the Palliative care team service to provide support and advice over the full seven days. As the hospital did not currently have this provision, some patients did not have access to specialist palliative support, for care in the last days of life in all cases.

• Work towards meeting the requirements of the key performance indicators of the National Care of the Dying Audit (NCDAH) 2016.

• Continue to consider ways to improve staff recruitment and retention such that it meets the national recommended levels.

• Play services should be developed and a play specialist employed.

• The trust should ensure incidents occurring in the ED are investigated thoroughly and all staff are included in the dissemination of the outcomes.

• The trust should ensure nurse to patient ratios in the ED are managed in relation to the individual needs of patients based on acuity.

• The trust should ensure that RTT is met in accordance with national standards.

• The trust should ensure that standard for patients receiving their first treatment within 62 days of an urgent GP referral is met.

• The diagnostic department should ensure all policies and procedures are up to date.

• The diagnostic imaging department should ensure they have a recent audit from their Radiation Protection Advisor.

• The diagnostic imaging department should monitor their waiting times and reporting times.

• The diagnostic imaging department should ensure staff attend mandatory training in line with the trusts target.

• The maternity services should ensure medication locks are suitable and do not allow unauthorised patient access.

• The maternity services should ensure there is a clear procedure documented for pool evacuation.

• The trust should consider improving the environment in the Day Assessment Unit waiting area as flooring could be a trip hazard and the room is unwelcoming.

• The maternity services should ensure a robust mechanism is in place to monitor and audit abortion HSA4 notification completion.

• The maternity services should ensure resuscitation trollies are fully stocked with items that are in date, at all times.

• The maternity services should ensure cleaning schedules are adhered to and audit is appropriately used to monitor this in the obstetric theatres.

• The children's service should address the lack of storage space and cramped conditions on the Kipling ward.

• The children's service should develop transition planning for children with long term conditions approaching adulthood.

• The children's service should improve efficiency of appointment and clinic booking systems to avoid long delays in accessing paediatric review and to improve efficiency.

Professor Sir Mike Richards

Chief Inspector of Hospitals