Our rating of services went down. We rated it as requires improvement because:

• Patients were not always protected from avoidable harm. There were limited effective systems in place to assess and monitor the ongoing care and treatment to patients, including monitoring patients for signs of clinical deterioration.
• Staffing levels and skill mix were not always sufficient to meet the needs of patients; as a result patients did not have their care and treatment carried out in a timely manner.
• There were not effective systems in place for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.
• Risk assessments were not consistently completed to inform the development of individual care plans that included actions to mitigate identified risks and individual needs appropriately.
• Staff did not always effectively support patients who lacked the capacity to make decisions about their care. This meant their individual wishes may not be considered.
• The governance arrangements and culture at the hospital did not always support the delivery of high-quality person-centred care.
• Medicines were not managed effectively and staff did not follow policies and procedures to ensure these were stored, administered and disposed of safely.
• Emergency equipment was not consistently checked to ensure it was fit for purpose and available when needed.

However,

• Staff did treat patients with dignity and respect. Patients felt supported and said staff cared for them well.
• Safeguarding was seen as a priority by nursing staff, who understood how to protect patients from abuse.
• Patients’ pain was regularly assessed and monitored. They received pain control as needed.
• People who use services, carers and family members were involved and encouraged to be partners in their care and in making decisions, and received support they needed.

The inspection team included two advisors with specialist knowledge of hospital theatres and infection control. During the inspection we spoke with 16 staff, in a range of roles, including healthcare support workers, housekeepers, nursing staff, doctors and managers. We also observed care and spoke with 12 patients and visitors. We visited a sample of elderly care and rehabilitation wards, surgical and maternity wards.

Patients told us that they were happy with the care and treatment they received. One patient told us; “Doctors and nurses have explained things well and I know what to expect. Staff are calm and respectful and have answered all my questions.” We saw that patients’ needs were assessed and treatment and care was delivered in line with their needs.

We found that the hospital was kept clean and procedures were in place to prevent and control the spread of infections. Patients were positive about the standards of cleanliness. Most commented that they had observed staff wash their hands frequently, and use gloves and aprons when necessary.

Patients said that staff had the right skills, saying, for example; “I am amazed at the levels of calm and competence of the nursing and care staff,” and “Nothing is too much trouble for the nurses.”

Some patients said that there were not always enough staff available however. We found that some wards often had fewer staff than expected. The trust was aware of this and was recruiting additional staff.

We did not speak to people who used this service as part of this review. We looked at a 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.

Hampshire Hospitals NHS Foundation Trust was established in January 2012 as a result of the acquisition by Basingstoke & North Hampshire NHS Foundation Trust of Winchester & Eastleigh Healthcare Trust.

The trust provides a full range of elective and emergency medical and surgical services to a local community of 600,000 patients in Basingstoke, Winchester, Andover and the surrounding areas in Hampshire and West Berkshire. It provides services from Andover War Memorial Hospital, Basingstoke and North Hampshire Hospital and the Royal Hampshire County Hospital. Outpatient and assessment services are provided from Alton, Bordon and Romsey Community hospitals, and the Velmore Centre in Eastleigh.

Royal Hampshire County Hospital (RHCH) is one of the acute district hospitals, and is based in the city of Winchester, Hampshire. The hospital has approximately 457 beds, and they had 44,273 emergency attendances in ED, and 211,418 outpatient attendances last year.

The RHCH provides a full range of general hospital services including accident and emergency, general and specialist surgery, general medicine, maternity and gynaecology, intensive care, rehabilitation, chemotherapy, diagnostic services, out-patient clinics and paediatric care.

The hospital employs approximately 654 clinical staff. They do not outsource for any contracted staff, and non-clinical staff are employed in all of the support functions such as portering, facilities management and catering provision.

We undertook this inspection of Hampshire Hospitals NHS Foundation Trust as part of our comprehensive inspection programme. The trust was in priority band 6 according to our Intelligent Monitoring system (with band 1 being the highest risk and band 6 being the lowest risk).

The inspection of RHCH took place on 28 to 31 July 2015. The full inspection team included CQC senior managers, county managers, inspectors and analysts. Doctors, nurses, allied healthcare professionals, ’experts by experience’ and senior NHS managers also joined this team.

We reviewed the following core services provided at RHCH: urgent and emergency care, medical (including older people’s) care, surgery, critical care, maternity and gynaecology services, children and young person’s services, end of life care, and outpatient and diagnostic services.

Overall, we rated RHCH as ‘good’. We rated it as ‘outstanding‘ for providing caring services, and good for safe, effective, responsive, well-led care.

We rated all services as RHCH as ‘good’ with end of life care as an ‘outstanding’ service.

Our key findings were as follows:

Are services safe?

• Staff were encouraged to report incidents and there was learning from incidents to improve the safety of services locally and across the trust.
• In diagnostic imaging, staff were confident in reporting ionised radiation medical exposure (IR(ME)R) incidents and followed procedures to report incidents to the radiation protection team and the care quality commission
• Clinical areas, such as wards, theatres and clinics were visibly clean with appropriate cleaning schedules.
• Staff followed infection control procedures and these were monitored. Staff in some areas were working to improve hand hygiene practices and environmental infection control standards, after having done audits.
• Medicines were appropriately managed and stored. However, fridge temperatures were not being regularly checked and monitored on the surgical wards.
• Anticipatory medicines (medicines prescribed for the key symptoms in the dying phase ie pain, agitation, excessive respiratory secretions, nausea, vomiting and breathlessness) were prescribed appropriately.
• Equipment was checked and stored appropriately in most areas but this needed to improve in surgery and on some medical wards specifically for resuscitation equipment.
• Overall, staff had a good understanding of safeguarding adults and children although more staff needed to attend training.
• More staff needed to complete mandatory training.
• Patients’ were assessed and monitored appropriately, for example, risk assessments were complete. However, the early warning score needed to be used consistently in surgery, and a tool was required for outpatients, for patients whose condition might deteriorate.

• The hospital had a higher than expected number of avoidable harms (pressure ulcers and falls) against their own targets. The trust was taking action to improve this, for example, care bundles were introduced to appropriately assess and treat patients.

• Critically ill children attending the emergency department were immediately referred to a paediatrician. There was a protocol for the transfer of critically ill children to a specialist care from the Southampton and Oxford retrieval team (SORT). The SORT team would provide specialist staff to support the child during the transfer.

• Medical staffing levels across the hospital were appropriate. National recommendations were followed, for example, for consultant presence in the emergency department, maternity, critical care and end of life care. There was consultant presence in the hospital over seven days with the exception of surgical services; there was 24 hour consultant cover arrangements across all services. Consultants in children and young people services were working additional sessions because of vacancies with junior doctors at middle grade level. This additional working was not sustainable in the long term.

• Nursing staffing levels were identified at trust level using an appropriate acuity tool. Planned staffing levels across all areas were higher than minimum recommendations. The hospital had a significant number of vacancies particularly in medical and older people’s care, surgery and children’s and young people’s services. Staffing levels were monitored and action was taken to fill vacancies from bank staff. Agency staff were not used. However, some medical and surgical wards did not always meet safe staffing levels. Nursing staff were coping by working longer hours, sharing staff or staff skills across shifts. Patients on these wards told us their needs were being met. The trust was implementing actions to mitigate and reduce the risks, for example, by developing skills in health care assistants and having ongoing recruitment campaigns, including employing staff from overseas.

• Midwifery staffing levels did not meet national recommendations but staff worked flexibly and could provide one to one care for all women in labour.

• Radiographers worked alone overnight covering imaging services for the hospital and the emergency department. Radiographers reported a heavy workload and raised concerns over manual handling issues. Between 10.00pm and 8am, radiology was supported by an overnight outsourced radiologist service. Staff identified delays in the process to authorise request and provide advice on imaging which meant delays in the patient diagnosis.

• The new regulation, Duty of Candour, states that providers should be open and transparent with people who use services. It sets out specific requirements when things go wrong with care and treatment, including informing people about the incident, providing reasonable support, giving truthful information and an apology. The trust monitored duty of candour through their online incident reporting system. Senior staff we spoke with were aware of duty of candour and talked about the importance of being open and transparent with patients and their families.                

Are services effective?

• Staff were providing care and treatment to patients based on national and best practice guidelines. In some areas guidelines had been unified across the trust for consistency of care.
• Services were monitoring the standards of care and treatment. Patient outcomes were similar to or better than the England average. There were action plans to address where outcomes were worse when compared to the England average.
• Patients who had suffered a stroke would be taken to the Royal Hampshire County Hospital as this was the designated receiving unit for the specialist treatment of stroke in Hampshire. For October 2014 to December 2014, the hospital performed better than other trusts for meeting standards for specialist assessments, thrombolysis and provision of physiotherapy and occupational therapy and discharge processes. The hospital was similar to other trusts for care on the stroke unit, multi-disciplinary working and standards of discharge standards. The hospital performed significantly worse than other trusts in providing speech and language therapy and scanning.
• Patients received good pain relief across all services.
• Patients, particularly older patients, were supported to ensure their hydration and nutrition needs were met.
• Staff were supported to access training. Many staff had a high level of competency having undertaken specialty specific qualifications. There was evidence of regular staff appraisal, although clinical supervision varied.
• Staff worked effectively in multidisciplinary teams to centre care around patients. This included working with GPs, community services, other hospitals. There were innovations in electronic records and the use of video conferencing in end of life care that enabled information to be shared about patient’s clinical needs and preferences across the trust, and with community and GP services. However, paediatric inpatient physiotherapy was not sufficient for children and young people with Cystic Fibrosis and this was of concern.
• Seven-day services were well developed, particularly for emergency patients. There was support from therapists, pharmacy and diagnostic services was less well developed.

• Staff had appropriate knowledge of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards to ensure that patients’ best interests were protected. Guidance was available for staff to follow on the action they should take if they considered that a person lacked mental capacity. Notification of Deprivation of Liberty Safeguards applications were correctly submitted to the Commission. However, capacity assessments were not always documented or regularly reviewed in patient care records.
• ‘Do Not Attempt Cardio Pulmonary Resuscitation’ (DNACPR) forms were not always appropriately completed and did not include, for example, an assessment of the patient’s mental capacity.

Are services caring?

• Staff were caring and compassionate and treated patients with dignity and respect. There was a culture in the hospital of understanding and responding to patient’s individual needs. This covered clinical and non-clinical staff such as porters who recognised the importance of their role in providing good quality care.
• Patient feedback was overwhelming positive across all services.
• We observed outstanding care for critical care patients, children and young people, patients having end of life care and patients attending outpatient and diagnostic imaging services. The staff had an ethos of providing person centred care and developed trusting relationship with patients and their families.
• Staff maintained patient’s confidentiality, privacy and dignity in all areas, although the layout of bay areas in Victoria Ward may have compromised patient’s dignity at times
• Patients and their relatives felt involved in their care and treatment, staff provided information and explanations in a way patients could understand. Patients felt that their views and considerations were listened to and acted upon.
• Records of conversations were detailed on patient records. This meant staff always knew what explanations had been provided and reduced the risk of confusing or conflicting information being given to relatives and patients
• Patients and their families were supported by staff emotionally to reduce anxiety and concern. There was also support for carers, family and friends for example, from the chaplaincy, bereavement services for patients having end of live care, and counselling support where required.
• Data from the national surveys demonstrated that the hospital was similar to other trusts. Patients were very satisfied and would recommend the care they received.

Are services responsive?

• Services were being planned to respond to increases in demand, staff capacity and patient needs. There was some innovation in models of care, for example, ambulatory care and early supported discharge. There was also joint work with partners, for example, to in-reach services for psychiatric assessment. Children’s and young people services had reduced the number of beds to respond to staffing issues. Other areas were working on how to increase capacity.

• Bed occupancy in the hospital was below the England average of 88%, although this was higher on surgical wards. It is generally accepted that at 85% level, bed occupancy can start to affect the quality of care provided to patients, and the orderly running of the hospital.

• The trust was not meeting the national emergency access target for 95% of patients to be admitted, transferred or discharged within 4 hours. Ambulance handovers over 30 minutes were often delayed and patients often had to wait in the emergency department for admissions.
• Many medical patients were often on outlier wards (a ward that is not specialised in their care). However, this did not happen during the inspection and information demonstrates that these patients were regularly assessed.
• Patient bed moves happened frequently, including at night. Staff were ensuring that patients with lower dependency needs were moved and patients had not expressed concern about their moves.
• The trust was achieving the 31-day cancer waiting time diagnosis-to-treatment target and the 62-day referral-to-treatment target, although this had not been met in June 2015.
• The hospital was achieving the 18-week referral-to-treatment time target for medical patients. The target had been met in surgery between April to December 2014 but was not being met between January to March 2015. The target was not being achieved in orthopaedics and ophthalmology.
• The majority of patient who had cancelled surgical procedures for non-clinical reasons were re-booked for surgery within 28 days.
• The trust was meeting national waiting times for diagnostic imaging within six weeks, outpatient appointments within 18 weeks and cancer waiting times for urgent referral appointments within 2 weeks and diagnosis at one month and treatment within two months.
• The trust cancellation rate for appointments was 11%; the England average was 7%. Many of these clinic cancellations were at short notice. The reasons for this varied and included cancellation for staff sickness, training and annual leave. There was a plan to address this but this was in development. Patients were not appropriately monitored to ensure the timeliness of re-appointments.
• Women were able to make choices about where they would like to deliver their babies. They had access early pregnancy assessment and their preferred ante-natal clinics. Women in the early stages of labour had access to telephone support.
• Patient discharge was effectively supported. Patients were regularly reviewed and discharge coordinators worked to improve the discharge of patients with complex care needs. The hospital had problems with increasing delays transfer of care for community services and was working with partners to improve this.
• Support for patients living with dementia was well developed, for example, there was specialist support, appropriate assessment, a sunflower symbol was used and staff had good awareness and training. Support for people with a learning disability needed further development. Although there was support for carers, the hospital needed a flagging system or passport to identify and support patients, and some staff identified the need for further training.
• The trust offers a number of one stop clinics. The breast unit, for example, offers appointments to patients within two weeks following GP referral. The referrals were initially received into the central booking office and prioritised by consultants. Patients who attended the one stop clinics, would see a clinician, have a biopsy taken and see a radiologist if required. If a cancer diagnosis was suspected, patients were told before leaving the clinic and an appointment given to discuss the outcome and treatment options. This unit provided a responsive service for patients who were anxious in relation to a potential cancer diagnosis.
• Patients having end of life care were identified by a Butterfly symbol so that staff were aware of their needs and those of their family.
• There was a hospital at home service to deliver care to those patients identified as being in the last days or hours of life. The service was 24 hours and seven days a week. Multidisciplinary team working and innovations in electronic records and the use of video conferencing in end of life care also facilitated rapid assessment and access to equipment.
• Patients having end of life care had multi-disciplinary care focused on their physical, mental, emotional and social needs. Patients could have a rapid discharge to home arranged within 24 hours. However, there were delays to the rapid and fast track discharge processes (within 48 hours) and processes were being improved to meet national standards.
• All wards we visited provided care for patients in single sex accommodation bays, in line with Department of Health requirements.

• Complaints were handled appropriately and there was evidence of improvements to services as a result. Some services, however, were not responding to complaints in a timely way.

Are services well-led?

• All services identified the plans to build a new Critical Treatment Hospital as the overall strategy for the trust and there were in-depth plans towards this across services. However, some services did not have specific strategies and plans in the short and medium term to respond to priorities. Some consultants identified concerns with the plans for the new hospital.
• Services had effective clinical governance arrangements to monitor quality, risk and performance. The Outpatients department needed better processes to manage risk and quality.
• Most staff told us overall they had good support from the local clinical leaders and staff engagement was good.
• Many staff identified the visibility and support of the chief executive of trust.
• Joint working between Royal Hampshire County Hospital and Basingstoke and North Hampshire Hospital varied. This was important to improve standards, share good practice and develop efficient and effective services across the trust. This was well developed in the emergency department, critical care and end of life care.
• The leadership for end of life care was outstanding. There were robust governance arrangements and an engaged staff culture all of which contributed to driving and improving the delivery of high quality person-centred care. This was an innovative service with a clear vision and supportive leadership and board structure.
• Patient engagement was mainly through survey feedback however, there was some innovation, for example afternoon tea sessions with stroke patients and their families and ‘through your eyes’ a listening event to surgery.
• The trust had a WOW Award scheme to recognise outstanding service. Staff could be nominated by patients or their colleagues. Recognition through the WOW Awards had led to high levels of staff satisfaction throughout the service

• Ideas to innovative and improve services were encouraged. There was participation in research, quality improvement projects, and innovation in developing new roles for staff, such as the Majors practitioners, volunteers caring in dementia, and advanced critical care practitioners.

We saw several areas of outstanding practice including:

• The trust was developing innovative new roles for staff, for example, majors practitioners in the emergency department and advanced critical care practitioners.
• Every medical and care of elderly ward had an activity coordinator who planned and conducted different activities for patients after consulting them. The activities included range of things such as arts and craft, music, dance, group lunches and movie time.
• ‘Afternoon tea’ session was held for patients and their relatives in the stroke wards. This gave patients an opportunity to share their experiences, peer support and education. The session was also attended by a member of stroke association team who delivered educational sessions related to care after stroke. Patients were also given information about support available in the community.
• A nurse led eight bedded day unit in the admissions and discharge lounge for patients who required certain medical interventions: patients were referred to this service by the medical consultants and this service was helping to meet needs of patients who required medical intervention without prolonging their stay in the hospital. Patients were highly complimentary about this service.
• When patients with complex needs on care of elderly wards were discharged to their new home, they were escorted by a member of nursing or therapy staff who spent up to an hour with patients in their new home. This had helped in offering elderly patients with emotional support.
• The early supported discharge team helped stroke patients for up to six weeks following their discharge from the hospital. The staff felt that this gave continuity of care and supported the patients in achieving their goals following the discharge
• Once a week the librarian attended the ward round in order to source relevant literature to assist the professional development of staff.
• Critical care career pathways were developed to promote the development of the nursing team.
• The critical care unit had Innovative grab sheets that detailed the essential equipment to care for each patient in the event the unit had to be evacuated. These included pictures of the essential equipment, so non-clinical staff such as portering staff could help collect the equipment ensuring medical and nursing care of patients was not interrupted.
• Pregnant women were able to call Labour Line which was the first of its kind introduced in the country. This service involves midwives being based at the local ambulance operations centre. Women who called 999 could discuss their birth plan, make arrangements for their birth and ongoing care. The labour line midwives had information about the availability of midwives at each location and were able to discuss options with women and their partners. Labour Line midwives were able to prioritise ambulances to women in labour if they were considered an emergency. The continuity of care and the rapid discharge of ambulances when they are really needed, have been two of the main benefits to women in labour The Labour line had recently won the Royal College of Midwives Excellence in Maternity Care award for 2015 and they were also awarded second place in the Midwifery Service of the Year Award.
• The breast care unit is a fully integrated multi-disciplinary unit that was pioneering intraoperative radiotherapy for breast cancer at the Royal Hampshire County Hospital.
• The specialist palliative care team provided a comprehensive training programme for all staff involved in delivering end of life care.
• The cardiac palliative care clinic identified and supported those patients with a non-cancer diagnosis who had been recognised as requiring end of life care.
• The use of the butterfly initiative in end of life care promoted dignity and respect for the deceased and their relatives.
• There was strong clinical leadership for the end of life service with an obvious commitment to improving and sustaining care delivery for those patients at the end of their lives.
• All staff throughout the hospital were dedicated to providing compassionate end of life care.

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

Importantly, the trust must ensure:

• Patients in the ED are admitted, transferred or discharged within national target times of four hours.
• There is an appropriate system to identify patients with a learning disability.
• Resuscitation equipment is appropriately checked and items are sealed or tagged.
• Medicines are appropriately managed and stored in surgery
• The early warning score is used consistently in surgery.
• Venous thrombo-embolism assessment occurs on admission for surgical patients.
• Staffing in radiology complies with guidance so that staff do not have heavy workloads and manual handling risks and staff have access to appropriate advice.
• There is effective partnership working so that children and young people with mental health needs (CAMHS) have timely assessment and care reviews.
• Children with cystic fibrosis are supported by appropriate paediatric physiotherapy.
• The outsourced diagnostic imaging service is appropriately monitored and managed to reduce delays.
• There are appropriate processes and monitoring arrangements to reduce the number of cancelled outpatient appointments, and ensure patients have timely and appropriate follow up.

In addition, the trust should ensure :

• There is a named lead nurse for children in the ED as per Royal College of Paediatric and Child Health guidelines (2012)
• Staff receive appropriate training and there is a formal process in place for staff to follow to meet requirements of the Duty of Candour.
• Staff maintain Infection control procedures - peripheral cannula care and catheter care and hand hygiene - at all times.
• Nurse staffing levels comply with safer staffing levels guidance.
• Medicines are appropriate managed and stored in maternity and gynaecology.
• Continued action to significantly reduce the incidence of pressure ulcer and falls.
• Equipment in the Maternity unit and outpatients is appropriately checked.
• The level of staff undertaking safeguarding adults and child training needs to meet trust targets.
• The trust target of 80% for mandatory training is met.
• The availability of medical notes for outpatient clinics continues to improve and this should be audited.
• There is a formal method to identify patient’s whose condition might deteriorate in the outpatient clinic.
• Clinical audit programmes continue to develop.
• Nursing staff receive formal clinical supervision in line with professional standards.
• Controlled drugs in liquid form are managed and stored appropriately in all the medical wards.
• All staff have a clear understanding of the Mental Capacity Act and Deprivation of Liberty Safeguards and mental capacity assessments are always documented or regularly reviewed in patient care records.
• There is guidance around the frequency and timeliness of bed moves so that patients are not moved late at night and several times.
• Review single sex bay arrangements on Victoria Ward to ensure patients privacy and dignity is not compromised.
• Review the need for developing a Critical Care outreach service.
• There is a critical care rehabilitation pathway.
• Paediatric critical care guidelines are reviewed and updated.
• There is a clear process and assurances for critical care staff who have been redeployed elsewhere in the hospital to return to the unit when a patient is admitted to the critical care unit.
• Information for patients is available in accessible formats.
• All DNACPR order forms are consistently completed accurately and in line with trust policy.
• Review the process for ‘fast-track’ discharge to meet the standards for 90% standard to be discharged with the right level of care within 48 hours if there preferred place of death is home.
• Safety Thermometer audits to allow staff, patients and their relatives to assess how the ward has performed in Maternity and gynaecology.
• There is access to seven day week physiotherapy for children and young people with cystic fibrosis.
• Complaints are responded to within the trust target of 25 days and there are formal methods to feedback complaints to staff.

Professor Sir Mike Richards

Chief Inspector of Hospitals