People told us they received very good care at St Richard's hospital. One person said it was a, "Fabulous place and we are very lucky to have it. The staff are faultless". Everybody that we spoke with was very happy with the care and felt they were well looked after.

We saw that significant improvements had been made in the assessment and care of people with dementia or elderly people who presented with confusion. A trust wide dementia lead had been very proactive in introducing new ways of working and supporting staff caring for patients. More work was planned with an emphasis on dementia care being the responsibility of all staff rather than the role of a few specialist staff. A draft Dementia Strategy was awaiting Board approval.

We also saw that significant reduction in the crude mortality rates for the trust had continued over an 18 month period. The number of deaths related to chronic obstructive pulmonary disease, pneumonia and heart failure showed an on-going decrease.

Staff were competent at identifying patients at risk of deterioration and used the escalation processes effectively to improve patient outcomes. On the day of our inspection visit, all areas of the hospital were calm and ordered. Patients were being assessed swiftly in the accident and emergency department and treatment was initiated in a timely manner, in order of priority.

During our inspection we visited Boxgrove Ward (specialising in patients with dementia), Fishbourne Ward (Escalation Ward due to winter pressures on hospital beds), Lavant Ward (stroke care), The Patient Discharge lounge, Medical Assessment Unit (MAU), and Accident and Emergency (A&E). We spoke with 13 patients who had dementia or possible dementia and their relatives. We also looked at the care records of patients with dementia. We spoke with 34 members of staff who were on duty in the areas we visited. We also left comment cards and boxes throughout the hospital on the day of our inspection, these cards encouraged people to write down any comments they had about the quality of care provided by the hospital to patients with dementia. The four comment boxes were left in the hospital for a week before being collected. We had 17 comment cards returned to us, all of which were from relatives of patients with dementia. All of the comments we received on these cards were complimentary about the care that their relatives had received in the hospital. One comment card said, ‘Every single dementia patient is different and Fishbourne Ward do their upmost to deal with this challenging aspect of mental health by treating everyone as an individual. My mum can be ‘difficult’ but through it all they have striven to find her ‘way’ – exceptional!’ Another comment card said, ‘My very elderly mother is presently being cared for by the excellent team on Boxgrove. She is being treated with compassion, humour and dignity. All the staff I have come into contact with have been communicative and very helpful in a difficult and prolonged illness’.

We saw that patients were assessed on admission using a dementia tool. However, the hospital did not have a specific dementia pathway that followed this initial assessment. We found that the planning of care for patients with dementia varied across the areas of the hospital that we inspected. On Boxgrove Ward we found that patients were kept safe because their risks were appropriately managed by the staff. We also saw that staff worked closely with other providers and services to ensure that specialist assessments were completed and safe hospital discharges were facilitated. However on the other Wards and Units we visited some aspects of record keeping did not always reflect that staff had good understanding of the ways to provide care and support that met people’s care and welfare needs.

We spoke with two relatives who told us the hospital and its staff were “wonderful”. One person said “I know he is really well cared for here the staff are so kind, nothing is too much trouble for them”. Another told us, “He is not always easy but the staff don’t panic and are kind and caring”.

We spoke with two staff who told us they enjoyed working with patients on the ward. One nurse told us, “It is busy here but we have a great team which helps a lot”. Another said, “We do have a lot of patients with dementia and you really feel for them and their families, but sometimes it is hard to give them the one to one care they need because we are so busy”.

We found that the hospital had processes in place to liaise with other health professionals and care providers. However, we found some examples where opportunities to gather information about patients had been missed. Therefore the hospital missed the opportunity to share valuable information with other care providers when those patients were discharged.

We found that the hospital had procedures in place to monitor and ensure the quality of the service that patients were receiving.

Everyone we spoke to was very positive about the care they received at St Richard’s hospital.

We spoke to one patient who told us they were well cared for and that they “couldn’t get any better service anywhere”. They also said they were not wanting to go home as they were being so well looked after.

One person looked at the nurse who was caring for her and said, teasingly, “Oh, they are alright, I suppose.” They then laughed and said actually they were absolutely brilliant and even made decent tea.

People were complimentary about the care they had received. One person said, "The care here is superb, if I was to pay £1000 a day I couldn’t get better treatment. I am more than satisfied".

We visited Graffham ward and the Fernhurst centre. We also visited the intensive care unit and the theatre suites. On each ward we found that, overall, care was planned and delivered to meet the needs of the individual patients.

We found the wards, departments and units we visited were adequately staffed with appropriately qualified nurses and doctors to ensure that patient care was delivered safely. Staff told us they were sometimes very busy but never at a level such that care was compromised.

We also looked at how the trust managed complaints made about the services provided by the hospital. We found comprehensive systems in place to ensure that each complaint was properly investigated and that any lessons learned were put into action across the trust.

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.

Throughout the hospital people told us they were pleased with teh quality of care they received at St Richard's hospital. They said that staff were kind and helpful and that they thought there were enough staff on duty to meet people's needs. People said they were always treated with dignity and respect by the staff.

Women we spoke to in the maternity unit were confident about the quality of care they received. We were also told that new parents were well supported by staff on the neonatal unit and that they trusted the staff to care for their babies well when they were not with them.

Patients told us that the hospital was very clean, and that staff observed infection control

procedures by wearing protective clothing and washing their hands frequently.

All of the many people we spoke to and questioned about the care they received at St Richard’s hospital said something positive about the hospital. The very few negative comments we received were about people’s situation and dislike of being in hospital rather than a reflection of the care provided at St Richard’s. People talked to us in detail about their illnesses and injuries and how the hospital had managed them. They were, mostly, very forthcoming in their praise of the hospital staff. We heard about how staff did little things that were perceived as making a real difference to how people felt about their stay. Everyone said that they were impressed by the hard work and dedication of all levels of staff. They felt that nothing was too much trouble and that staff genuinely cared about the quality of care they provided.

We spoke to relatives of people who were unable to speak directly to us and found that they also had a very positive image of the care provided at the hospital. Family members told us they felt involved and that their wishes were respected. They all said that their relative had been treated with kindness, dignity and respect at all times.

We spoke to other people who had professional links with St Richard’s but who were not employed by the trust. Without exception, they told us St Richard’s is a good hospital.

Western Sussex Hospitals NHS Foundation Trust became a foundation trust on 1 July 2013, just over four years after the organisation was created by a merger of the Royal West Sussex and Worthing and Southlands Hospitals NHS Trusts. St Richard's Hospital in Chichester, West Sussex is one of three hospitals provided by the trust.

The trust serves a population of around 450,000 across a catchment area covering most of West Sussex. The three hospitals are situated in the local authorities of Worthing, Chichester and Adur. These areas have a higher proportion of over 65's compared to the England average. The three local authorities have a lower proportion of ethnic minority populations compared to the England average.

Adur and Worthing are in the middle 20% in England for deprivation. Chichester is in the top 40% of least deprived areas in the country.

The hospitals provide 953 inpatient beds which include 77 maternity beds and 32 critical care beds. Of these, 430 are at St Richard's Hospital. The trust employs over 5,600 staff (Whole Time Equivalent at end of August 2015). In the year 2013-14, there were more than 127,000 inpatient admissions and 533,000 outpatient attendances; over 135,000 patients attended the accident and emergency department.

The trust annual income is around £403 million. The trust has made a surplus every year, since the merger of the predecessor trusts, up to 2014/2015 and has paid back £21 million of legacy debt.

We inspected this trust as part of our comprehensive hospital inspection programme. Our inspection was carried out in two parts: the announced visit, which took place on the 9, 10 and 11 December 2015 and the unannounced visit which took place on 21 December 2015.

Overall we found that St Richard's Hospital was providing outstanding care and treatment to the community it served. We saw many examples of very good practice across all areas of the hospital. Where we identified shortcomings, the trust was aware of them and was already addressing the issues.

The trust is one of the 16 members of NHS Quest, a member-convened network for Foundation Trusts who wish to focus on improving quality and safety within their organisations and across the wider NHS. The members of NHS Quest work together, share challenges and design innovative solutions to provide the best care possible for patients. The trust was also a winner of a Dr Foster Better, Safer Care at Weekends award.

There was a strong governance structure and assurance framework. The board executive and non-executive directors were clear on their responsibilities and understood the hospital well. The governance was organised through four cross-site divisions (medicine, surgery, women and children and core services), each had a consultant from that speciality as a Chief of Service.

Our key findings were –

The executive team provided an exemplar of good team working and leadership. They had a real grasp of how their hospital was performing and knew their strengths and areas for improvement. They were able to motivate and enthuse staff to ‘buy in’ to their vision and strategy for service development. Middle managers adopted the senior manager’s example in creating a culture of respect and enthusiasm for continuous improvement.

Innovation was encouraged and supported. We saw examples that, when raised directly with the Chief Executive and her team, had been allowed to flourish and spread across the services.

We saw respectful and warm relationships internally amongst staff teams, the wider hospital team and outwards to external stakeholders and the local community.

Across the hospital there was an embedded culture of learning from incidents. Staff were encouraged to have an open and honest attitude towards reporting mistakes and incidents that were then thoroughly investigated. There was strong evidence of learning from incidents both locally and across the organisation.

The hospital was performing better, and sometimes much better than comparable trusts across England on many measures. Where this was not the case, the trust had clear action plans and investigations ongoing to bring about improvements.

An example of this was the 4 hour Emergency Department (ED) target where new and innovative approaches coupled with strong monitoring systems had resulted in the trust meeting the target over 95% of the time. They were amongst only a handful of trusts to meet the quarter four target.

In 2014/15 the trust improved their infection control ratings for the sixth successive year.

There was good management of deteriorating patients and systems in place to allow early identification and additional support when a patient’s condition became unexpectedly worse.

Monitoring by the Care Quality Commission had not identified any areas where medical care would be considered a statistical outlier when compared with other hospitals. The trust reported data for mortality indicators, the summary hospital level mortality indicator (SHMI) and hospital standardised mortality ratio (HSMR). These indicate if more patients were dying than would be expected given the characteristics of the patients treated there. The figures for the trust were as expected. Information about patients’ outcomes was monitored. The trust participated in all national audits it was eligible for. Where improvements were identified, the trust was responding and was making progress implementing its action plans in order to improve the quality of care they were providing.

Across all disciplines and in all core services we found a good knowledge and understanding of the policies and guidance relating to safeguarding vulnerable adults and children. Trust staff were involved in local initiatives, working with other key agencies to improve outcomes for babies and children from challenging or vulnerable families.

Staff of all grades and from all disciplines contacted us to tell us about their belief that the St Richard's was a very good hospital. They talked with great pride about the services they provided and all agreed they would be happy for their family members to be treated there. They talked of their commitment to making sure they did their very best to provide optimal care for patients. They talked about initiatives to improve patient care they had been involved in.

Specifically, all consultants from St Richard’s Hospital who contacted us were very positive about how the trust provided services from this site. The majority of consultants employed at St Richard's responded to our invitation to submit written comments or to meet with us. They told us the executive team and medical director in particular, were supportive, encouraging of new ideas and approachable. They told us about the work that had been done to improve the mortality figures overall and in specific areas. This included the changes to the pathways for patients who suffered a fractured neck of femur where changes to the care and treatment of this condition had reduced the number of elderly patients who died as a result of this.

Medical, nursing and midwifery staffing levels were safe and allowed staff to provide good care. Staffing acuity tools were in routine use and staffing was reviewed frequently – in some areas such as ED this was done four hourly. However, there were areas where the trust did not meet the recommendations of professional bodies such as the royal colleges. This included medical staffing in the critical care unit and the number of supervisor of midwives. In both these cases the trust was already taking action.

Volunteers from across the hospital were also keen to tell us about how much they enjoyed working at the hospital. They told us they were supported and accepted as a part of the hospital team. Those working in clinical areas described a sense of belonging and felt their work helping people to eat and drink or occupying elderly patients was valued.

We received an unprecedented number of letters and emails from people who used the service prior to, during and after the inspection visit. The overwhelming majority of these were very positive and told stories of staff going above and beyond the expected level of care. Staff we spoke with were exceptionally compassionate when talking about patients and we observed kindness not only towards patients but towards each other whilst on site.

The results of the Friends and Family Test supported the views of the many patients who contacted us. In most areas the hospital consistently scored above the national average.

The commitment of staff to providing good care coupled with good strategic and operational planning led to a service that was responsive to the needs of individuals. We saw flexibility and a willingness to make local changes to improve how people were cared for. There were numerous initiatives that improved patient experiences and allowed them equal access to care. These included Learning Disability nurses visiting the ED, interagency joint working in the hospital and community and the Harvey’s Gang project.

The trust had introduced a ward accreditation scheme which was being rolled out.

Outstanding practice

We saw much that impressed us but of particular note was;

The positive attitude of outpatient and diagnostic imaging staff was an outstanding feature of this hospital. The outpatient nursing staff knowledge of vulnerable adult and safeguarding children and how they should proceed if concerns arose and compliance with training in this area. The management of medical records meant that more than 99% of full records were available to staff in clinics.

The level of 'buy in' from all staff to the trust vision and value base was exceptional. We were flooded with requests from staff wanting to tell us about specific pieces of work they were doing, how much they liked working for the trust and how supportive the trust executive team were of innovative ideas and further learning as a tool for improvements in patient care. The trust ambassadors worked to promote the positive work that the trust was doing to other staff and visitors.

Multidisciplinary working was a very strong feature across the hospital that resulted in better patient care and outcomes. There was clear professional respect between all levels and disciplines of staff. We saw real warmth amongst teams and an open and trusting culture. Exceptional examples of this included how 'Harvey's Gang' was growing and developing as more staff became involved in local initiatives such as the joint working 'Five to Thrive' protect and Family Nurse Partnership which improved outcomes for the children of young and vulnerable parents.

The trust had won a Dr Foster Better, Safer Care at Weekends award.

The level of feedback from patients and their families was exceptional. We received many letters and emails before, during and after the inspection visit. It was overwhelmingly and almost exclusively positive. Amongst the hundreds of people who contacted us to say how good the hospital was, there were just a few who felt unhappy with the care they had received.

We were contacted by many consultants working at the hospital, from across all specialities who wanted to tell us about how good it was to work at the trust. They wanted to tell us the executive team were approachable and supportive, that their ideas were listened to and they felt the trust provided very good care to most people.

In ED the focus on access and flow, coupled with the work being done with local stakeholders such as GP's and CCG's had resulted in a department that was mostly able to meet the key performance targets. People were seen quickly and were not kept in the department overly long.

The attention and consideration of peoples' individual needs and genuinely patient centred care was evidenced across the hospital. The work of the learning disabilities nurse specialists, the neonatal outreach nurses and the SPCT were all notable. In the critical unit the staff remained focussed on the person and not the technology, with people being pushed out of the unit in a wheelchair, if they were well enough, to help them maintain a sense of normality. Staff encouraged fathers to stay overnight on the postnatal ward to provide support to their partner and to begin the bonding process with their baby.

The trust wide learning from incidents and complaints was well embedded. In all areas of the hospital, staff gave examples of where improvements had been made as a result of complaints, comments or incidents.

The executive team provided exceptional leadership and had a very good understanding of how the hospital was working in both the longer term (through a sound assurance framework) and on a day to day basis (through a regular ward and department presence and open door sessions). There was clear team work amongst the executive team and their positive leadership style filtered down through middle managers to local managers.

The Medicines division was involved in a trust wide NHS Quest initiative which focused on improving quality and safety. This involved the trust taking part in collaborative improvement projects for sepsis and cardiac arrest. Work was in progress on these initiatives at the time of our inspection.

The ‘Knowing Me’ initiative along with the other initiatives to improve hospital experiences for people with dementia.

The involvement of a learning disabilities nurse for patients admitted who had a learning disability improved the outcome and experiences for this group of patients.

The level of staff engagement and involvement in service planning was exceptional, with the Trust Ambassadors giving a very clear message about staff ‘buy in’ and belief in the work they were doing.

The very strong governance systems allowed the trust to focus on safety and improved patient outcomes at all levels. Local managers could see how the wards and departments in their control were performing. The board involvement allowed proper assurance through involvement in governance meetings.

The trust executive had a very sound understanding of their hospitals. They did not need to look up how areas were performing as they were very aware of the areas of strengths and weaknesses.

However, we also saw things which the trust should review and take action where necessary;

The hospital should ensure all staff mandatory training is up to date.

The hospital should ensure the numbers of chemotherapy trained nursing staff on duty reflect the established number required at all times.

The Medicine Division should recruit consultants to ensure an adequate level of medical expertise which reflects the England average.

The hospital should ensure all staff receive an annual appraisal to ensure their continuous professional development needs are met.

The hospital should ensure there is an adequate supply of pressure relieving equipment for patients on all wards.

The hospital should ensure continuity on recording of medicines fridge temperatures on all wards, and that emergency medicines are checked in accordance with their own policy, to ensure they are always readily available for use in an emergency.

The hospital should review the levels of medical and nursing staff on each shift in critical care, in line with established national guidelines. The hospital should also consider the working practices of existing senior physicians during the pilot phase of a telemedicine model of care.

The hospital should review the security and storage of hazardous waste and chemicals on the critical care unit.

The trust should ensure grading of referrals occurs within acceptable timescales.

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

The trust should ensure staff who work in the diagnostic imaging department and who provide care to children have the appropriate level of safeguarding training.

The trust should ensure drugs in OPD that require refrigeration are stored in a temperature checked fridge, which should be used for the sole purpose of storing drugs.

The trust should review the availability of supervisors of midwives.

Professor Sir Mike Richards

Chief Inspector of Hospitals