We carried out a focused inspection on 23 September 2014 to review the trust’s progress in meeting the requirements of the warning notice that was issued on 28 March 2014 for regulation 10 (Quality monitoring of the services provided) against the regulated activity of ‘Treatment of Disease, Disorder or Injury’, specifically to sections 10(1)(a)(b), (2)(c)(i). We inspected the Accident and Emergency Service and the Medical Care service. As this was a focused inspection, we did not inspect every key line of enquiry under the five key questions.

Our key findings were as follows:

• The trust had taken significant actions to meet the concerns contained in the warning notice and that the warning notice was now to be removed.

Recommendations for improvement for the trust were:

• The trust should continue to embed effective training and staff appraisals systems in place to ensure trust targets are met
• The trust should continue to monitor the capacity and demand of the ED to ensure all patients are assessed within the 4 hour target time.
• The trust should continue to review all areas of patient risk and ensure all areas of risk highlighted on the corporate risk register are reviewed within the prescribed timescales.
• The trust should continue to monitor all out of hours patient moves and embed the risk assessment process to achieve its target for 100% completion of these risk assessments.

Professor Sir Mike Richards, Chief Inspector of Hospitals

Northampton General Hospital (NGH) is an 800-bedded acute hospital. There are approximately 713 general and acute beds with 60 maternity beds, and 16 critical care beds. The trust employs 4,875 staff, including 531 doctors, 1,487 nursing staff and 2,857 other staff.

We carried out this inspection as part of our routine focused inspection programme. We completed a short notice focused inspection on the 25 to 27 July 2017and an unannounced inspection on 9 August 2017.

We determined the extent of this focused inspection following a review of information gathered and the findings from our previous inspection. This included an analysis of the trust’s performance and information from stakeholders. The hospital was previously inspected under our comprehensive methodology in January 2014, when the overall rating was requires improvement.

We found the trust has taken significant action to meet the concerns raised from the January 2014 inspection, particularly in establishing an inclusive and supportive staff culture with a clear focus on patient safety.

We rated the four core services we inspected (critical care, maternity and gynaecology, children and young people and outpatients and diagnostic imaging) as good overall. Combining these core service ratings with the ratings for the other four services we last inspected in February 2017, the overall rating for the hospital was good. All five key questions were rated as good (safe, effective, caring, responsive and well-led).

We found that:

• Staff were friendly, professional, compassionate and helpful to patients in all interactions that we observed.
• Patients told us that the staff had been caring towards them and all spoke positively about the staff in all areas inspected.
• We observed care being delivered by nurses, play specialists, medical, therapy, and auxiliary staff that interacted with children and young people in a very positive and caring manner.
• There was a positive culture towards reporting incidents and learning from these to improve patient safety in all areas inspected.
• There were effective systems in place to ensure that standards of cleanliness and hygiene were maintained.
• The design, maintenance, and use of facilities, premises, and equipment generally met all patients’ needs.
• Improvements had been made in some areas in the outpatient environment, which included the expansion of the chemotherapy suite and new equipment in the diagnostic imaging department.
• Medicines were generally stored and handled in line with the hospital’s medicines management policy.
• There were generally effective processes in place to ensure that adults and children in vulnerable circumstances were safeguarded from abuse. Staff in all areas were aware of the processes to identify and respond to patient risk and there were systems in place to monitor and manage risks to patient safety.
• Medical, nurse and midwife staffing levels met patients’ needs at the time of the inspection.
• Patients’ outcomes were being measured and were generally in line with national average. Action plans were in place to drive improvements.
• There was clear evidence and data upon which to base decisions and look for improvements and innovation. The unit participated in the Intensive Care National Audit and Research Centre (ICNARC) audit and performed better or as expected in six out of eight indicators.
• The critical care outreach team provided 24 hour cover seven days a week and assisted with the monitoring and treatment planning of deteriorating patients throughout the hospital, ensuring risks were responded to appropriately.
• Patients and their relatives were supported during their stay within critical care services and staff provided opportunities to discuss care and treatment. This was delivered in a way that promoted dignity and confidentiality at all times.
• The maternity and gynaecology service completed the national maternity safety thermometer and monitored safety performance through clinical dashboards.
• The children and young people’s service performed well in in a number of national audits including the National Neonatal Audit (2015) and the Epilepsy 12 audit (2014). Gosset ward was working towards achieving Bliss accreditation.
• Policies were based on national guidance produced by National Institute for Health and Care Excellence (NICE) and the royal colleges.
• Pain of individual patients was assessed and managed appropriately.
• There were systems and processes in place to ensure that staff had the necessary qualifications, skills, knowledge and competencies to do their jobs.
• Effective multidisciplinary working was clearly evident throughout the departments and services.
• There were appropriate processes and systems in place to ensure that information needed to deliver care and treatment was available to relevant staff in a timely manner.
• Patient’s consent was obtained in line with trust policy and statutory requirements.
• Services had been planned to take into account the needs of different people, for example, on the grounds of age, disability, gender or religion.
• Care and treatment was only cancelled or delayed when absolutely necessary.
• Access to services was generally effective and timely.
• Appointments were prioritised according to referral requests from GPs with urgent requests and cancer referrals booked within two weeks. The imaging department prioritised reporting higher risk examinations not seen by other clinicians.
• The hospital consistently met the referral to treatment standards over time.
• Waiting times for diagnostic procedures were better than England average.
• The service managed complaints swiftly, openly and constructive as part of a co-ordinated patient feedback system.
• The hospital staff worked with a variety of stakeholders and commissioners to plan delivery of care and treatment. There was a focus in providing integrated pathways of care, particularly for patients with multiple or complex needs.
• The leadership teams were cohesive and inclusive and were focused on delivering safe, high quality care and treatment for all patients.
• Staff felt there was a high level of staff engagement, which was positive and led to high levels of staff satisfaction.
• Staff believed in the leadership of the hospital and were proud of the organisation and its culture.
• Services had a clear vision, strategy, and objectives based on improving quality and safety in line with the overall trust vision.
• Leadership in services was well established and there was a clear focus on improvements and patient safety.
• Structured meetings were held throughout services to review all aspects of quality, risks and performance and high risks were escalated and monitored effectively.
• Effective governance arrangements were in place. There were structured meetings to review all aspects of performance, quality and risks and high risks were escalated through the services.
• Service risk registers reflected the risks within the service and there was evidence of ownership, mitigations having being implemented and ongoing monitoring.
• Innovation throughout staff teams was encouraged.

However, we also found:

• The critical care service was aware of the shortfall in band 8a specialist pharmacist support and was providing cover with a band 7 pharmacist. A business case had been put forward, which if successful, would ensure standards were being met.
• Medicines were not always stored safely behind locked doors or in restricted areas in critical care. We raised this with the trust and this was rectified immediately by the trust.
• There was effective working relationships and commitment to critical care between members of the multidisciplinary team. However, the trust was not meeting the national core standards for employment of allied professionals within critical care services.
• The critical care unit did not comply with the Department of Health’s Health Building Note 04-02 critical care unit’s standards; however, this had been risk assessed and was under review. Refurbishment plans were in place to address this.
• Not all medical staff in critical care had completed the required mandatory training.
• Hospital wide bed capacity affected the ability of the service to discharge patients to wards at the most appropriate time. Over eight hour delayed discharges were higher than the national average, however, action had been taken and improvement observed for patients waiting 24 to 48 hours.
• Single sex accommodation in critical care was not always maintained due to hospital wide bed pressures. Action was taken to protect patient’s dignity at all times.
• Not all doctors, nurse and midwives had had annual refresher training for safeguarding adults at level two in the maternity and gynaecology service. Action plans were in place to address this.
• The maternity service had had higher than expected caesarean rates and perinatal mortality rates over time. Whilst actions and mitigating actions had been taken, these had not always improved outcomes. The service continued to monitor and assess these potential risks to patients.
• There were not always effective systems in place regarding the storage and handling of medicines in the children’s outpatient department. The trust took immediate action to address this once we raised it as an urgent concern.
• Children or young people on Paddington ward could access the corridor to the delivery suite. This was a risk particularly for patients who may be at risk of self-harm or suicide. The trust took immediate action to address this once we raised it as an urgent concern.
• The pathway for patients who needed to cross the road between buildings had not been reassessed to ensure opportunities to prevent or minimise further harm were not missed. The trust took immediate action to address this once we raised it as an urgent concern.
• The child abduction policy was in draft and awareness was lacking in some areas of the service. The trust took immediate action to address this once we raised it as an urgent concern.
• Paediatric wards did not have the appropriate facilities to care for the increasing number of patients with mental health issues who could be at risk of self-harm or suicide.
• We found concerns about the fire exit in the fracture clinic. This had been addressed by the unannounced inspection and we found the service had also reviewed all fire exits throughout the service.
• Not all staff were compliant with infection prevention and control measures in the blood taking unit. We raised this with the service, and immediate actions were taken to review infection control precautions to mitigate risk. This had been addressed by the unannounced inspection.
• Not all staff had had the required frequency of mandatory training, including safeguarding.
• The controlled drugs cupboard in the pain relief clinic contained a variety of non-controlled drugs. This was not in line with medicines storage guidelines. We raised this with the service and this had been rectified by the time of our unannounced inspection.
• We observed poor infection control practices in both the blood-taking unit and the pain relief clinic. We raised this with the service and this had been rectified by the time of our unannounced inspection.
• Some staff in the diagnostic imaging department had limited understanding of the ionizing radiation (medical exposure) regulations (IR(ME)R) regulations themselves and five members of staff we spoke to were unable to locate where the employers’ procedures were kept. We raised this with the service and senior staff took immediate action to address this.

We saw several areas of outstanding practice including:

• The trust had a duty of candour sticker that would be placed into the patient’s notes when the duty of candour had been applied. This included, for example, staff name, date, name of person/patient receiving information, account of incident, details of incident and if an apology was offered.
• Two members of the critical care team had been nominated for the ‘Best Possible Care’ Awards. Patients and those close to them, as well as work colleagues, voted for staff members who had gone above and beyond to exceed expectations and had made a real difference to patient care.
• The ‘Chit Chat’ group was set up by the maternity service in 2016 to facilitate antenatal education, parenting advice and peer support for women with additional needs, including learning disabilities or anxiety. Staff said these meetings were two weekly and very well attended. This group meeting initiative had been nominated for two national awards and had won one at the time of the inspection.
• The maternity service reviewed and evaluated the provision of multi-disciplinary training when the service was chosen as one of the 10 pilot sites for enhancing patient safety. As part of the pilot, the service chose to concentrate on the fetal monitoring and team working and skills drills sections with the outcome that the service was able to deliver these training programmes completely internally (including Practical Obstetrics Multi-professional Training (PROMPT).
• Gosset ward was working towards achieving Bliss accreditation. This means the ward had undertaken exceptional work through the involvement of parents to encourage bonding with these very special babies which has helped to build the evidence for Bliss accreditation.
• Staff had developed an assessment tool to improve the monitoring and assessment of baby’s skin on Gosset ward. The ward was working with neonatal services from across the world (Canada and Turkey) to further develop the tool.
• The recruitment of 1.7 WTE advanced neonatal nurse practitioners (ANNP) onto the medical neonatal rota was helping to address recruitment issues in relation to junior doctors.
• The superintendent sonographer was very passionate about their service and had developed an excellent team which provided image quality assurance and peer review. They were able to detect team members’ weaknesses and pair them with other sonographers to help them develop. The ultrasound department conducted many audits and fed these back to ultrasound community in England.

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

The trust should:

• Review pharmacy provision to meet the needs of the critical care service and be in line with national guidance.
• Continue to review and monitor over eight hour delayed discharges in critical care and report incidents and mixed sex breaches using the electronic reporting system.
• Monitor staff mandatory training to ensure compliance with the trust’s target including annual refresher training for safeguarding adults at level two and safeguarding children level two and three.
• Continue to monitor caesarean rates and perinatal mortality rates in the maternity and gynaecology service.
• Review multidisciplinary support to critical care services to ensure national best practice is following, in relation to therapy support.
• To monitor allergy testing ampules ensuring use within their recommended expiry dates.
• The trust should consider improving the facilities for parents to stay overnight on paediatric wards.
• Continue to monitor and review the impact of patients admitted to paediatric wards with mental health issues.
• Continue to monitor and review the effect on children’s services due to the limited availability of psychologist support, particularly for children with long term conditions.
• Continue to monitor controlled drugs are effectively stored in outpatient areas.
• Continue to monitor fire exits are accessible at all times.

Professor Edward Baker

Chief Inspector of Hospitals