We undertook this inspection to follow up on concerns that were noted at our previous inspection on the 4/5 of February 2013. These related to the some records that did not contain accurate and sufficient information about the care and treatment provided and the lack of records of the qualifications undertaken by staff, in order to evidence that they had the skills and training to operate radiology equipment.

At this inspection we found that considerable action had been undertaken to address the previous concerns. This included staff undertaking training in records management, regular audits across the Trust to monitor standards of record management and the establishment of a patient document committee. We found that the records we looked at now contained the information necessary in order to protect patients from the risk of unsafe or inappropriate care and treatment.

People who use this service said that they felt supported by the staff to receive the care they need. They told us that every effort is made by the staff to help them maintain their mobility, independence and regain confidence to help them live independently when they are discharged. We spoke to many patients who said they felt included in their care, were able to express their preferences and contributed with goal setting for discharge. They were able to make choices in their daily activities and what food they wished to eat.

During our visit we spoke with people on two wards who had been in the hospital between 3 days and 5 weeks and they told us they were very happy with the care provided. In general they were confident that the doctors and nurses made the right decisions about their care and treatment but some were not always sure that they fully understood all the details. They said that when they asked or needed things explained in more detail the ward staff took time to explain things more clearly and were good at making sure people understood about their illness, their treatments and care, even at busy times.

General observations made by inspectors throughout the day found that overall staff talked politely, respectfully and treated patients with dignity when giving treatment or care. When we looked at a selection of nursing records and care plans we could see that these documents clearly recorded what treatment was required and received, together with important references to the patients’ ethnicity, religious needs and preferences.

During our visit we saw lunch being served both in the dining area and within the wards. Staff told us that they encouraged people to eat in the dining room whenever possible to help regain mobility and engage with other people. We saw that those people that needed some support and encouragement to eat their meal were treated calmly by staff in a dignified manner and given appropriate equipment to use. People told us they were always asked if they wanted a choice of drinks and that hand washing wipes were available for them to use prior to eating.

We asked people on each ward what they thought of the food, and they all reported that it was of good quality with plenty to choose from. On the day of our visit the food looked appetising and patients were keen to tell us that the food was always hot, well presented and there was an excellent roast dinner on Sundays. One person said “It’s the best hospital food I’ve had” and another person told us that “food is excellent here and I am a very fussy eater so not easy to please”.

• There were arrangements to keep service users safe from abuse which were in line with relevant legislation. The majority of staff had received training, were able to identify who might be at risk of potential harm and knew how to seek support or advice.
• The hospital was providing safe care. There were sufficient staff to meet the needs of patients although some services were heavily reliant on a temporary workforce. Recent recruitment campaigns both locally and overseas had been successful.
• The critical care unit had improved it’s out of hours medical cover since our last inspection. At the time of our last inspection one doctor out of hours was needed in multiple places at once including in theatre and attending to unwell patients. This inspection there had been a change in policy to ensure surgery had finished before the other medical staff would leave the hospital.
• Services were delivered by staff that were competent, trained and supported by their managers, to provide safe and effective care. The trust provided regular training and development opportunities for staff. The trust invested in research, for example, there was specialist research nurses in burns and plastics.
• Staff kept themselves, equipment and the premises clean. Staff demonstrated good hand hygiene practice and safe disposal of sharps and waste. Staff complied with national and trust processes to control and prevent the spread of infection.
• Medicines were stored, prescribed and given correctly and medicines fridge temperatures checked.
• Patients were given enough food and drink to meet their needs. The hospital had recently extended the range of teas available to include ginger and peppermint teas to hydrate patients suffering from post-operative nausea or gas. Pain levels were assessed, and patients received adequate pain relief.
• Staff understood and complied with the relevant consent and decision-making requirements of legislation, including the Mental Capacity Act, 2005.
• Staff provided compassionate and respectful care. Staff provided emotional support to patients and relatives and involved patients and those close to them in decisions about their care and treatment. During our inspection, we heard many examples of staff going ‘the extra mile’ to provide compassionate care that exceeded expectations.
• The hospital provided care and treatment in accordance with evidence-based guidance. Staff were aware of clinical guidance for patients with specific needs or diseases.
• There was an audit program that covered many areas of practice in the critical care unit. The unit looked for areas to improve. There was a positive culture to learning from things when they went wrong or went well.
• The hospital made improvements following learning from complaints and patient feedback. We saw managers fed back complaint learning to staff in staff newsletters. However, the trust did not always respond to complaints within the timeframe set out in the trust’s policy.

However:

• The hospital did not meet the British Burn Association National Burn Care Standards. This was because, as a specialist trust, the hospital did not provide the usual range of hospital services such as general surgery, mental health liaison and paediatric medicine. To reduce these risks, the trust had service level agreements with a nearby acute NHS trust to provide these services in a timely way, 24 hours a day, seven days a week.
• The critical care unit was not fully meeting the Guidelines for the Provision of Intensive Care Services 2015 but there had been an improvement since the last inspection. At the time of our last inspection critical care had no intensive care consultants but now had intensive care consultant cover Monday to Friday. However, the unit still lacked this cover out of hours and at weekends.
• Nursing agency usage was higher than was recommended for a critical care unit. The unit had a target of a maximum 50% usage, but the recommended level was a maximum of 20%.
• There were significant numbers of registered nurse vacancies predominantly in theatres and critical care and heavy reliance on temporary staff. However, the trust had systems and processes to mitigate the risk, for example a limit to how many agency staff could be allocated to each theatre. These services used regular agency staff to provide consistency and continuity.

• The trust’s admissions policy for surgical patients and critical care patients relied heavily on the individual judgement of the on-call consultant as to whether a patient met the criteria for admission to the hospital. For example, there was no specific criteria for burns patients around the total body surface area affected by the burns. There were also no specific criteria for significant co-morbidities. Comorbidity describes two or more disorders or illnesses occurring in the same person.
• Mandatory training rates including safeguarding and Mental Capacity Act modules for all staff groups did not always meet the trust target of 95%. However, at the time of inspection compliance had improved.
• The trust had struggled to meet both the 18-week referral to treatment and cancer targets. Five specialties were below the England average for non-admitted pathways for referral to treatment times.
• Plastic surgery department, sleep disorder unit and ophthalmology appointment cancellations by the hospital within seven days varied in the reporting period, none met their target. On the day cancellations by the hospital had stayed the same for a period but failed to reach their target.
• Resuscitation equipment within the plastic and burns department and maxillofacial department had some daily and weekly checks missing which was not in line with the trust’s policy.