People told us what it was like to be a patient in Milton Keynes Hospital. They described how they were treated by staff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because this inspection was part of a themed inspection programme to assess whether older people in hospitals were treated with dignity and respect and whether their nutritional

needs were met.

The inspection team was led by two Care Quality Commission (CQC) inspectors joined by a practising professional and an Expert by Experience, who has personal experience of using or caring for someone who uses this type of service.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

We observed care and spoke with staff and 38 patients on the acute female medical ward (Ward A) and the male cardiology and mixed sex high dependency respiratory ward (Ward B).

We spoke with patients about the food at the hospital. Most patients said they were happy with the food provided, and the choices available to them. They told us that the mealtimes, snacks and drinks were adequate. On Ward A five patients told us they were happy with the care they received. One patient

said they had been treated well and the nurses had taken the time to talk with them. Two people told us they felt safe.

On Ward B the patients we spoke with said that they knew the staff well as they were the same ones working there every day. One patient told us "I feel confident that I can approach staff" another told us, "The staff are very caring and nice". However, on Ward A one relative we spoke with felt that a lack of continuity of staff resulted in issues around staff knowing preferences and choices. Another relative stated they had seen several different nurses within the week and could not identify the person in charge.

We spoke with patients who told us they could not tell who were nurses and who were care assistants as the uniforms were so similar.

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

The people we spoke with on ward 20 said they were happy with the care and treatment provided. They said the ward was very clean. People told us they saw staff wash their hands, use hand rub or wear gloves and apron before carrying out care.

We spoke to people on ward 20. They told us they were happy with the care and treatment they received. They said they had been given enough information and had the opportunity to see their doctor and ask questions. People said staff treated them with respect and dignity.

People thought the hospital was clean and they saw staff washing their hands before performing duties.

In general patients told us that they were well informed and involved in decision making. They said that doctors and nurses introduced themselves and spoke to them in a way they could understand. The exception to this was ward 20 where a patient said that they had been told what was going to happen and that there had been no discussion. They also said that staff did not introduce themselves or ask permission to proceed with tasks.

Patients told us that staff cleaned their hands and used the hand gel. However, on ward 20 a patient told us that the doctor had examined them without cleaning their hands and that they were not aware of staff in general cleaning their hands.

A patient on ward 20 told us that each time a doctor came to see them that they asked the same questions again. They said that it was as though no one had recorded the previous conversation.

Staff told us that mandatory training was available and that this included infection prevention and control, fire awareness and evacuation procedures, equality and diversity and data protection. They also said that patients with infections were barrier nursed and their care planned according to an assessment of risk.

Milton Keynes University Hospital NHS Foundation Trust consists of one medium-sized district general hospital. The trust provides a full range of hospital services including an emergency department, critical care, general medicine including elderly care, general surgery, paediatrics and maternity care. In total, the trust has 517 hospital beds. In addition to providing general acute services, Milton Keynes Hospital increasingly provides more specialist services, including cancer care, cardiology and oral surgery.

We inspected Milton Keynes Hospital NHS Foundation Trust as part of our comprehensive inspection programme in October 2014. Overall, we rated this trust as “requires improvement and noted some outstanding practice and innovation. However, improvements were needed to ensure that services were safe, effective, and responsive to people’s needs.

We carried out a focused, unannounced inspection to the trust on 12, 13 and 17 July 2016, to check how improvements had been made in the urgent and emergency care, medical care and end of life care core services. We also inspected the maternity and gynaecology service.

Overall, we inspected all five key questions for the urgent and emergency care and medical care core services and found that improvements had been made so that both core services were now rated as good overall.

For the maternity and gynaecology service, at the last inspection, all five key questions were rated as good. At this inspection, we rated safety and well-led as good.

We found that significant improvements had been made in the end of life care service and that the key question of safe was now rated as good.

Applying our aggregation principles to the ratings from the last inspection and this inspection, overall, the trust’s ratings have significantly improved to be good overall. This was because four key questions, namely effective, caring, responsive and well-led, were rated as good, with safe being requiring improvement.

Our key findings were as follows:

• All staff were passionate about providing high quality patient care.
• Patients we spoke to described staff as caring and professional. Patients told us they were informed of their treatment and care plans.
• The emergency department was meeting the 95% four hour to discharge, or admission target, with a clear escalation processes to allow proactive plans to be put in place to assist patient flow. For July 2016, the department was performing at 96%.
• The emergency department leadership team had significantly improved the department’s performance in meeting the four hour target to improve safety in seeing and assessing patients. The department leaders had implemented a range of systems and processes to drive improvements throughout the service.
• The Hospital Standardised Mortality ratio (HSMR) was significantly better the expected rate and generally outcomes for patients were positive.
• Whilst bed occupancy was very high, at 97%, above the threshold of 90%, patient flow was generally effective in the service.
• The service performed well for referral to treatment times; scoring 97% across the medical specialities.
• Improvements had been made in the completion and review of patients’ ‘do not attempt cardio pulmonary resuscitation” forms.
• The trust had established a maternity improvement board to review incidents and risks and to drive improvements in the service. Information was used to develop the service and continually improve.
• There was a lower rate than the national average of neonatal deaths. The maternity improvement board was monitoring this to make further improvements in the service.
• The culture within the nursing and midwifery teams was caring, supportive and friendly.
• Safety concerns and risks were monitored regularly in the maternity service and plans were in place to address areas of concern. Changes in practice and training had been put in place following lessons learned from incidents.
• Staff knew how to report incidents appropriately, and incidents were investigated, shared, and lessons learned.
• Staff understood their responsibilities and were aware of safeguarding policies and procedures.
• There were generally effective systems in place regarding the handling of medicines.
• Equipment was generally well maintained and fit for purpose.
• Staffing levels were appropriate and met patients’ needs at the time of inspection.
• Patients’ individual care records were written and managed in a way that kept people safe
• Standards of cleanliness and hygiene were generally well maintained. Reliable systems were in place to prevent and protect people from a healthcare associated infection.
• Mandatory training generally met or was near to meeting trust targets.
• Appropriate systems were in place to respond to medical emergencies. Appropriate systems and pathways were in place to recognise and respond appropriately to deteriorating patients.
• Patients’ needs were assessed and their care and treatment was delivered following local and national guidance for best practice.
• Staff morale was positive and staff spoke highly of the support from their managers.
• Local ward leadership was effective and ward leaders were visible and respected.

We saw several areas of outstanding practice including:

• The medical care service had a proactive elderly care team that assessed all patients aged over 75 years old. This team planned for their discharge and made arrangements with the local authority for any ongoing care needs.
• The medical care service ran a ‘dementia café’ to provide emotional support to patients living with dementia and their relatives.
• Ward 2 had piloted a dedicated bereavement box that contained appropriate equipment, soft lighting, and bed furnishings to provide a ‘homely’ environment for those patients requiring end of life care.

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

• The emergency department did not fully comply with guidance relating to both paediatric and mental health facilities. The paediatric emergency department had a door that was propped open, allowing access by all staff and patients presenting potential security risks The ED did not a have dedicated mental health assessment room that had had a robust risk assessment, allowing equipment in the room to be used as missiles. The trust took immediate actions to address this during the inspection to make these areas safe.
• Initial clinical assessments were not always carried out in a timely way in the paediatric area, and escalation for medical review and assessment was inconsistent. This was escalated to the trust who took immediate actions during the inspection to address this. This was followed up on the third day of inspection and all children had been clinically assessed within the 15-minute period. The trust also ensured this was actively monitored on an ongoing basis.
• There were inconsistent checks of resuscitation equipment throughout the department, not in line with trust policy. The trust took urgent action to address this during the inspection and to monitor this on an ongoing basis.
• Staff, patients and visitors did not observe appropriate hand washing protocols when entering/leaving the department or when moving between clinical areas. The trust took action to address this and to monitor on an ongoing basis.
• Some patients’ privacy was not respected when booking in at the reception desk in the emergency department when the department was busy.
• The non-invasive ventilation policy was out of date and had not been reviewed. New guidance relating to this had been released in March 2016, which meant there was a risk that staff were not following current guidelines. The service was aware that it was out of date and was planning to review this; however, there was no time scale for this.
• The medical care service did not have a specific policy for dealing with outlying patients, and therefore, there was no formal procedure to follow in these instances.
• External, regional health service planning had affected the maternity service’s development plans.
• In the maternity service, some examples were shared with inspectors of poor communication, inappropriate behaviours and lack of teamwork at consultant level within the service. From discussion with senior managers, it was clear that some issues had been recognised and active steps were being taken to optimise communication and team working. Such behaviours were not observed during the inspection.
• Not all medical staff had the required level of safeguarding children’s training.
• There was poor compliance with assessing the risk of venous thromboembolism (VTE) and the maternity service had actions plans to place to address this concern.

Importantly, the trust should:

• Review and monitor the access and security of both the adult and paediatric emergency departments.
• Monitor the facilities available for respecting the privacy and confidentiality of patients and relatives during the booking in process in the adult and paediatric emergency departments.
• Monitor the initial clinical assessment times within the paediatric emergency department.
• Monitor that recommended checks are carried out on all resuscitation equipment and documented the adult and paediatric emergency departments.
• Review and monitor the mental health assessment room to ensure it is fit for purpose in the adult emergency department.
• Monitor the effectiveness of staff, patient and relatives’ adherence to infection control procedures within the adult and paediatric emergency departments.
• Monitor staff compliance with mandatory training requirement to meet the 90% trust target in the adult and paediatric emergency departments.
• Ensure that all resuscitation and emergency trolleys are fit for purpose and robust audits are completed.
• Ensure that agency staff have appropriate induction with evidence of completion.
• Review the isolation facilities available on Ward 17 for patients with infections.
• Review the storage of hazardous chemicals and needles to ensure that no unauthorised people could have access.
• Review the non-invasive ventilation policy, incorporating the new guidance available.
• Review the consistency of consultant cover out of hours and at weekends across the medical wards.
• Review the arrangements for timely discharge of patients from the AMU.
• Review the procedures for the management of outlying patients.
• Review the process for recording the number of bed moves for patients, including out of hours and at weekends.
• Review the specific arrangements for caring for patients with autism.
• Review the completion of assessments for venous thromboembolism (VTE) to ensure patients’ safety needs are met.
• Review arrangements for monitoring the cleaning of equipment in the maternity service.
• Review the provision of pain relief provided to women in labour to ensure patients’ needs are met.
• Review the arrangements for post-operative recovery to ensure mothers and babies can be cared for together, unless in emergencies.
• Monitor the safeguarding children’s training provision for medical staff in the maternity service.

Professor Sir Mike Richards

Chief Inspector of Hospitals