Wycombe Hospital is part of Buckinghamshire Healthcare NHS Trust. The hospital offers a wide range of surgical services and specialist medical care for stroke and heart conditions. The hospital also offers specialist cancer and urological services. The hospital has 250 beds.

The hospital is the area’s major hub for planned surgical care. Surgical teams carry out over 24,900 operations every year. Wycombe Hospital sees more than 36,000 inpatients and 145,000 outpatients a year. Wycombe is also home to a modern midwifery-led maternity unit aimed at providing a more home-from-home environment for women and their partners.

We carried out a focused unannounced inspection visit on 7 September 2016. We inspected the medical, surgical and end of life care services provided at this location. During the inspection, we also followed up issues identified at the inspection in February 2014 and March 2015 relevant to the service types inspected.

Overall, medical care, surgery and end of life care were rated as ‘requires improvement’. All the services required improvement to provide safe care. Medical care and end of life care services required improvement to provide effective care and surgery required improvement to provide responsive care. We rated all of them ‘good’ for caring and ‘well led’ services.

Are services safe?

By safe, we mean people are protected from abuse and avoidable harm.

• Staff felt confident and able to report incidents. The trust recognised the importance of learning from incidents to improve the care provided to patients. However, staff could not always describe where learning from incidents had changed clinical practice. Staff demonstrated a good understanding of duty of candour and gave examples where they had used this to support patients.

• Staff did not always follow the trust’s medicine management policies and procedures.For example for controlled drugs orders and monitoring medicine fridge temperatures. Staffing shortages in the pharmacy department resulted in reduced support to departments and we found evidence of some unsafe practices, including out-of-date medicines and some medicines not stored securely on the wards.

• Patients’ records were not always completed in full, including the signing of medicine charts and completion of an assessment of the patient’s capacity. We found that patient’s did not always have a diagnosis, management plan or care plan which assessed risks to their care. Some DNACPR forms we inspected were not completed according to national guidelines. The trust audits had identified this as an area for further improvement.

• Patient confidential information was not always stored securely and there was a risk of unauthorised access.

• Not all staff were trained in areas that the trust had identified as essential in providing safe care and treatment. Staff completion of statutory and mandatory training was not in line with the trust’s target in some areas, this included safeguarding children and vulnerable adults level 2, duty of candour, infection control, medicines management, basic life support and tissue viability.

• Staff were completing the Five Steps to Safer Surgery and the most recent trust patients’ record and observational audit showed 95% compliance.However, during the inspection, we observed some members of the theatre team were not engaged for each step of the process and this, potentially, could placing patients at risk of harm.

• In general, all clinical areas were visibly clean and staff had access to sufficient equipment to provide safe care and treatment. Staff in general adhered to infection prevention and control practice on the wards and in theatres. However, the mortuary trolley was found to be dirty with no agreed cleaning schedule in place and deceased clothing was not appropriately stored while awaiting collection.There was also one cubicle on In the Cardiac and Stroke Receiving Unit (CSRU), where deterioration in the décor presented an infection control and patient safety risk.

• Patient’s safety and daily staffing information was prominently displayed for patients, staff and visitors to read, as part of the trust’s open and honest approach.

• In the operating departments, the anaesthetic logbooks were not complete, to provide assurance the daily safety checks had been completed and equipment was fit for purpose, prior to patient surgery. On some of the wards, staff had not completed the daily checks on the resuscitation equipment in line with the trust policy, to ensure it was ready for use in an emergency. Staff had concerns over night time security at the hospital.

• Staffing was planned using a recognised Department of Health patient acuity and dependency tool, which had clear guidance on levels of care and inclusion criteria for clinical staff to follow. There were escalation processes in place when staffing shortages were identified.

• Overall, staffing levels in the surgical departments met the planned levels for theatre, nursing and medical staffing. The trust achieved this using bank and agency staff for some shifts, particularly in the operating departments. The cardiac and stroke unit did not always meet their own planned staffing levels. In August 2016, 28 shifts were understaffed by at least one member of staff and four of these were understaffed by two members of staff. Medical staffing for the end of life care did not meet national guidance.

• Staff were knowledgeable about the hospital’s safeguarding policy and clear about their responsibilities to report concerns. Staff routinely assessed and monitored risks to patients. They used the national early warning score to identify patients whose condition might deteriorate.

Are services effective?

By effective, we mean that people’s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best possible evidence.

• Staff planned and delivered people’s care and treatment in line with current evidence based guidance, standards and best practice across the medical and surgical services. While there was some evidence of evidence-based care for end of life care this was not constantly applied across the hospital. For example the trust did not have a protocol for withdrawal of treatment, which was not in line with national guidance

• The hospital participated in national and regional audits and undertook a local audit programme. The hospital had received an A grade in the Sentinel Stroke National Audit Programme (SSNAP) which is the highest possible grade. The hospital also performed better than the England average in the myocardial ischaemia national audit project (MINAP) for the treatment of patient with non-ST-elevation infarction (nSTEMI).For the surgical services results from these audits showed patient outcomes were in keeping with the national average.

• Staff assessed and managed patient’s pain appropriately and had access to the acute pain service for advice and support. However, for patients receiving end of life care staff did not use a standardised pain assessment tool to ensure staff delivered a consistent approach to pain measurement or management.

• Patients identified as having end of life care needs were assessed, reviewed and their symptoms managed effectively.However, for medical patients there was lack of consistently in care planning for patients.

• Patients told us they had made an informed decision to give consent for surgery. The most recent informed consent audit showed medical staff were not completing all consent forms and patient care records to the expected trust and national standards.

• There was some variability in staff awareness of their responsibilities regarding the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards (DoLs). We saw that patient’s capacity was not always formally assessed when decisions were being made on behalf of patients who were deemed to lack capacity.Staff did not always recognise when a patient was being deprived of the liberty and apply for a DoLS order. We observed a patient who had received chemical restraint without the correct order in place.

• Staff had good access to training and professional development. The specialist palliative and end of life care staff were skilled and competent to perform their roles effectively.

• Multidisciplinary working was embedded across all the wards. Staff worked effectively within their team and with other teams to provide co-ordinated care to patients, which focused on their needs.

• The hospital had systems in place to ensure they provided care for inpatients seven days a week. This included access to on-call theatre and diagnostic imaging staff in an emergency and consultants carried out ward rounds seven days a week. The hospital performed above the national and regional average for most standards set out in the NHS services, seven days a week guidance.

Are services caring?

By caring, we mean that staff involve and treat people with compassion, kindness, dignity and respect.

• In all areas, patients and relatives were positive about the caring attitude of staff, their kindness and their compassion. All patients we spoke with would recommend the service to their friends and family.This was supported by data collected for the Friends and Family Test.

• Staff took time to ensure patients and their relatives understood their care and treatment. Patients told us they felt involved in their care and understood their treatment plans. Medical and nursing staff showed sensitivity when communicating with patients and relatives.

• Staff we spoke with valued and respected the needs of patients and their families. Patients’ emotional, social and religious needs were considered and were reflected in how their care was delivered.

• We observed staff did not maintain patients’ privacy and dignity at all times when providing care and treatment in both the operating department and on ward 2a.

Are services responsive?

By responsive, we mean that services are organised so they meet people’s needs.

• The trust worked in partnership with local commissioners to plan and deliver services, to meet the needs of local people. Some elective surgery such as for ear, nose and throat (ENT) and breast surgery had been relocated to the hospital to improve efficiency and a prompter service for patients. Stroke services had been merged to provide a single specialist provision to reduce patient transfer between two sites.
• Patient with chest pain or stroke had access to rapid assessment and treatment via the cardiac and stroke receiving unit (CSRU). The stroke unit held a transient ischaemic attack (TIA) clinic everyday prioritising the most urgent cases.These services took referrals directly from GP’s and paramedics.
• In the surgical division, there was a significant backlog of patients requiring pre-operative assessment. The division had not achieved 90% of patients being seen and admitted within 18 weeks of referral.
• Staff took account of the needs of different people, including those with complex needs, when planning and delivering services. There were adequate facilities to meet individual’s spiritual and cultural needs. We observed staff using alternative methods to communicate with non-verbal patients and making flexible arrangements for families to support patients living with dementia and learning disabilities. However, patient assessments, measuring the suitability of the environment for people with dementia and people with a learning disability, were consistently low scoring.
• The trust operated a rapid discharge home to die pathway which served to discharge a dying patient who expressed wanting to die at home within 24 hours. However, there were some external delays with funding and care packages for patients with complex needs and patients who expressed a wish to die at home, did not always get to do so.
• Complaints were investigated thoroughly to improve the quality of care. However, this was not effective on the medicine wards where staff told us learning from complaints was not always shared at ward meetings.

Are services well led?

By well led, we mean that the leadership, management and governance of the organisation assured the delivery of high-quality person-centred care, supported learning and innovation, and promoted an open and fair culture.

• The staff we spoke with told us they were passionate about providing safe and compassionate care. Staff enjoyed working at the hospital and told us they found managers and their team supportive. There was a clear sense of teamwork and collaboration between wards and members of the multidisciplinary team. Staff told us there was an open and transparent culture within the hospital.Most staff felt the leadership of the trust and within the division were visible and supportive.

• There was a clear governance structure in place, which linked in with the trust’s overall governance structure.Meetings took place at all levels of the divisions and were well attended by members of the multidisciplinary team (MDT) staff reported on quality, safety and performance. However, minutes of all meetings at all level were not always recorded and therefore it was not always possible to evidence what had been discussed.We identified a number of concerns around staff not following practices designed to keep patients safe which had not been identified by the trust.

• There was a local and a national audit programme and staff had knowledge of the audits that directly linked to their clinical area. The clinical governance teams had an oversight of audit performance and there was evidence of improvement in clinical audit results.

• Systems were in place to gather patient feedback and departments and the division had used this feedback make changes to services. The trust had set up a patient panel to ask for opinions and suggestions in what mattered to them regarding developing plans for end of life care. There had also been a public consultation,“Better Healthcare in Buckinghamshire” which had fed into plans to centralise the stroke and cardiac services.

• However, patient views had not been sought in the planning stages for the design and improvement of cardiac and stroke service. The trust had not audited the views of the bereaved as recommended by the National care of the Dying audit hospitals) NCDAH) 2014/15

We saw several areas of outstanding practice including:

• Excellence reporting had been introduced in the operating departments to encourage staff to report and learn from examples of good practice.

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

Importantly, the hospital must ensure:

• Staff comply with all aspects of the trust’s medicine management policy and associated standard operating procedures.

• Medicine stock is checked in line with policy and expired or unwanted medicines are disposed of in a timely manner.

• Staff working in theatres fully comply and are engaged with each of the stages of the five steps for safer surgery.

• All staff working in theatres comply with the trust’s uniform policy, in particular changing their scrubs, if they leave and then return to theatre.

• Pharmacy staffing is as planned to provide clinical pharmacy support to departments.

• Anaesthetic machines and resuscitation equipment have appropriate checks and are safe to use

• Patients’ medical records are stored securely and confidential information is not accessible to unauthorised staff.

• Patients’ have care plans which accurately reflect their needs and risk assessments are completed in a timely manner.

• Patients who are thought to lack the capacity to make a decision about their care have a formal mental capacity assessment.

• All staff are up to date with their mandatory training.

• Action is taken to ensure compliance with informed consent.

• A standardised pain assessment tool across the hospital to ensure end of life patients have their pain accurately assessed and responded to.

• The end of life care strategy is completed and published and all clinical staff are aware.

• Prepare a protocol for withdrawing treatment as recommended in the 2015 National Institute of Clinical Excellence guidelines and train clinical staff in its use.

• The new end of life care plans “Getting it right for me” and the associated “Getting it right for me patient held record” are used by clinical staff for all end of life care patients in the trust.

In addition the trust should ensure:

• The pharmacy service does not supply out of date British National Formularies.

• Audits completed by the pharmacy service are used to drive improvements and progress should be demonstrated over time.

• There is a clear process to demonstrate the mortuary trolley has been cleaned, with appropriate dates and times recorded.

• Suitable sealed storage is in place for deceased patients’ belongings in the bereavement office and a documented cleaning schedule for the storage receptacle to be cleaned at least weekly.

• Nursing staffing levels are as planned and this takes account of staffing of the TIA clinic.

• The standard of record keeping is monitored through regular audits and action taken for areas of non- compliance.

• Medical staff receive yearly appraisals.

• All staff understand the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards and are confident to apply this in the clinical setting to safeguard patients.

• The learning from complaints and incidents is shared with all members of staff.

• The hospital should consider reviewing night time security arrangements to ensure staff are protected at work.

• The privacy and dignity of patients is maintained at all times in the operating departments.

• Meetings held within the division of surgery and critical care have documented actions to provide assurance that concerns are being addressed.

• Advance care plans are fully documented in order to comply with patient’s wishes.

• Information leaflets on advance care planning, what happens when someone dies and how to register a death are available and up to date for patients and families

• Audit the views of bereaved relatives to make care change to improve to the service

• Porters, cleaners and mortuary staff receive standardised formal end of life care training.

• All staff are aware of how to contact different faith ministers to visit the hospital out of hours.

• All patient identifiable information is kept confidential at all times, including patient’s namesin ward areas.

Professor Sir Mike Richards

Chief Inspector of Hospitals

This visit focussed on in patient medical services for older people. We spoke to people on wards 5B, 3B, 4A, 4B and 9. 5B was the designated acute medicine ward for older people. At the time of our visit the other wards also contained a significant proportion of older people (over 65 years).

We spoke with 10 older people across the five wards. People told us they were happy with the care and treatment they received. One person said “ the care is brilliant, couldn’t ask for anything better”. Everyone we spoke with 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 told us sometimes they thought there was not enough nursing staff. Although this had not affected their care, it did mean some people did not ask for help as they did not want to “bother staff”.

People thought the hospital was clean and they saw staff washing their hands before performing duties. One person said “the ward is spotless, the cleaners do a thorough job”.

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.

Wycombe Hospital is one of seven hospitals that form part of Buckinghamshire Healthcare NHS Trust. The hospital is an acute district general hospital and provides a range of elective medical, and surgical services, as well as midwifery led maternity and outpatient services. Emergency services are provided for cardiac and stroke patients.

A comprehensive inspection of the acute services of Buckinghamshire Healthcare NHS Trust was conducted in March 2014. Following this inspection, urgent and emergency care and end of life care were rated as required improvement overall. However, end of life care was rated as ‘inadequate’ for providing effective services at Wycombe Hospital.

We therefore inspected this urgent and emergency care services and end of life care services as part of an unannounced focused inspection.

Overall, the end of life care services at this hospital ‘requires improvement’. However, the service had demonstrated improvement since the last inspection. The ratings from this inspection did not affect the overall ratings for the trust (from March 2014) which was ‘requires improvement’

Our key findings were as follows:

End of life care

• Overall we rated this service as ‘requires improvement’. This was the same as the previous rating in March 2014. However the service had improved its rating in two of the five domains we inspected in providing an effective and caring service.

• During this inspection we found improvements. Nursing and medical care had improved and patients received better symptom control and anticipatory drugs for pain relief. Patients nutrition and hydration needs were being assessed.

• Patients and relatives gave examples of compassionate nursing care. They felt involved and informed regarding their care and treatment.
• The specialist palliative care team was well led and staff were passionate about improving the quality of services. Staff across the hospital provided good emotional support for patients. The chaplaincy provided one to one spiritual support and worked closely with the bereavement officers to ensure relatives received a sensitive and individual service following the loss of a loved one.
• Records were not always stored securely and in places could be accessed by patients and relatives. Do not attempt cardiopulmonary resuscitation (DNACPR) forms were not consistently completed.
• Patients being taken to the mortuary frequently arrived without any identification wrist bands. Technicians were reliant on a nurse from the ward coming down to the mortuary to identify the patient.
• Staffing levels in the mortuary were not safe. Technicians were often working long hours alone without support and they did not have appropriate equipment for bariatric (obese) patients.
• Patient areas were clean and staff followed infection control practices.
• There were interim care plans in use following the withdrawal of the Liverpool Care Pathway in 2014. However, these care plans, called Hearts and Minds – end of natural life, were not consistently completed to provide holistic care for patients. Staff did not have a clear understanding of end of life care and ceilings of care, which would involve the cessation of all invasive treatments and non-essential medication, were not consistently applied. The trust was working on a care pathway called “getting it right for me” and had involved staff and patients to develop this.
• The trust had participated in the 2013/14 National Care of the Dying Audit – Hospitals (NCDAH) and did not achieve five of their seven key performance indicators (KPI’s) but was similar to the England average for most of the clinical indicators of care. Local audit to monitor the effectiveness of services was not well developed.
• There was evidence of good multi-disciplinary working practices on the elderly care wards, with doctors, nursing staff and allied healthcare professionals working together to ensure that patients at the end of their life were cared for in the correct setting. However, there could sometimes be discharge delays. The trust was still not monitoring patients preferred place of death although rapid discharge was being supported by the specialist palliative care team.
• There was good support from the specialist palliative care team and referrals, once completed, were responded to within 24 hours. Support and advice was available 24 hours a day seven days a week. Training was available for staff in relation to caring for patients at the end of their life.
• The hospital did not have a central register to identify a patient who was on an existing end of life care pathway and this could delay their care and treatment. However, a new electronic record, the Buckinghamshire Care Co-ordination Record was being implemented to ensure that patients who were receiving end of life care were identified more easily.
• Patients at the end of their life were still being moved several times around the hospital despite trust guidelines recommending that patients on the end of life care pathway should not be moved.

• The director of nursing holding responsibility for end of life care at trust board level. A new trust strategy was being developed but communication around this needed to improve. A review of the service had been undertaken and some key areas of work were in progress which included the new care pathway and the treatment escalation plan. A dashboard was being used to monitor some key indicators relating to care but audit to monitor the quality and safety of end of life care services needed to develop. The trust had held engagement meetings with staff and patients to establish how best to move the end of life care service forward.

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

Importantly, the trust must ensure that:

• There is a timely replacement for the Liverpool Care Pathway and all staff follow the current interim policies.
• Staff complete the end of life care plans (Hearts and Minds – end of natural life) appropriately to National Institute for Health and Care Excellence (NICE) guidelines for holistic care.
• All staff consistently and appropriately complete the DNACPR forms and discussions between patients and relatives are recorded in patient records.
• Staffing levels in the mortuary are reviewed to give staff adequate rest time between shifts and to reduce the levels of lone working.
• Mortuary staff have appropriate equipment for bariatric (obese) patients to reduce the risk of harm to staff from inappropriate manual handling.
• Deceased patients are clearly and appropriately identified when being transferred from wards to the mortuary.
• All staff involved in end of life care can identify a patient at the end of life (12 months) to ensure that referrals to the specialist palliative care team are made in a timely manner.

In addition the trust should ensure that:

• Infection control risks, in relation to storing patients’ belongings in the bereavement office, are addressed.
• The provision of interpreter services enable patients who do not speak English as their first language to receive the same level of care as other patients at the end of their life
• The multi faith room environment at Wycombe hospital is improved so that the facilitate can accommodate more than two people and can offer privacy for those wishing to pray.
• Communication from senior management teams to all staff providing end of life care to improves.
• Patients who receiving end of life care are not moved unnecessarily between wards.

Professor Sir Mike Richards

Chief Inspector of Hospitals