HIN 2

 

 

 

 

Written evidence from the Care Quality Commission

 

At the session on Monday, 2 February I agreed to write to you about the factual accuracy comments which Hinchingbrooke Health Care NHS Trust sent CQC in response to the draft report shared with them in November 2014.  I thought it would also be useful to set out the process for factual accuracy checking of our inspection reports.  I would also like to clarify some of the statements I made during the course of the session.

Factual accuracy process

Following a comprehensive inspection, the CQC inspection team produces a draft report which goes through internal quality assurance and editorial processes prior to being presented at the CQC National Quality Assurance Group (NQAG).  The NQAG is made up of CQC staff, all of whom are independent of the inspection.  At the NQAG the report, supporting evidence and draft ratings are challenged by the panel members.

Once the ratings have been determined the report, including the ratings, is sent to the provider as a draft to check for factual accuracy.  The provider is given a log to record and submit any factual accuracy challenges, which must be done within 10 working days.

Minor challenges to factual accuracy are generally typos or errors in numbers whereas major challenges are where a provider is able to provide evidence that a statement within the report is factually incorrect.  The factual accuracy process is not an opportunity to challenge the professional judgements of CQC, but is an opportunity for the provider to challenge the accuracy and completeness of the evidence on which the ratings are based; there is a separate process for requesting a formal review of the ratings.  Any factual accuracy comments that are upheld can result in a change to one or more rating.  Where this is a possibility, an additional NQAG will be held to consider the implications of the changes on the ratings


Hinchingbrooke Health Care NHS Trust factual accuracy detail

Mr Abdel-Rahman alleged at the oral evidence session with the Committee that the Trust highlighted 300 factual inaccuracies in the report of which the CQC agreed to 65%.

The Trust returned two factual accuracy logs – one each on the provider report and the location report.  The factual accuracy challenge from the Trust amounted to 285: 194 related to the location report and 91 to the provider report.  To give a flavour of the challenge, I have included an extract (Annex A) showing some of the challenges which were accepted and some which were not.  I have attached both logs (Annex B) which show the text from the draft report under challenge, the challenge from the Trust and our response to each challenge. 

Given the scale of the factual accuracy challenge, we took the unusual step of convening an additional internal group to consider each line in detail, prior to the NQAG to agree any relevant amendments to the final report and consideration of any implications on the ratings awarded.

The degree of challenge from the Trust on this draft report was unprecedented in our experience.  Many of the challenges raised were extremely detailed and in many cases they sought to add context or amend the wording of the report in a way which could potentially change the ratings we had indicated in the draft report.  In other cases they were simple challenges to typos, names or spelling.  We have been responsive to the Trust and have considered every line.  Throughout the process we have sought to enter a dialogue with the Trust to reach a common understanding of the problems revealed without compromising the independence of the report.  The approach taken by the Trust to this process, we believe, is symptomatic of an organisation not recognising the scale of the challenges it faces.

Following the challenge at the PAC the factual accuracy logs (annexes A and B) have been reviewed to provide a greater level of insight into the types of challenges made by the trust.  I hope this enables committee members to have a more rounded view of the trusts definition of an error and how the CQC have responded.

 

We have classified the 285 submissions into separate categories as far as is possible.  Once items for clarity, repeated challenges and non-applicable submissions were removed from the log, the number of challenges reduced to 225: 155 relating to the location report and 70 to the provider report.  As far as possible we have made every attempt to ensure any possible challenge around data inaccuracy/dispute has been accounted for in this grouping.

Of the 225:


The table below provides further detail on the breakdown of the challenges:

Hinchingbrooke Health Care NHS Trust Location and Provider Factual Accuracy Challenge Summary

 

Classification

Not agreed/amended

Partially agreed/amended

Agreed/amended

Total

Rating challenge

6

9%

 

 

 

 

6

3%

Revision of wording

15

23%

29

60%

52

47%

96

43%

Typo

 

 

 

 

15

14%

15

7%

Data inaccuracy

13

20%

5

10%

15

14%

33

15%

Removal of sentence

9

14%

2

4%

3

3%

14

6%

Reporting period

 

 

1

2%

4

4%

5

2%

Corroboration

3

4%

2

4%

 

 

5

2%

Sample size

3

4%

2

4%

4

4%

9

4%

New evidence

4

6%

2

4%

4

4%

10

4%

Compliance actions

2

3%

 

 

4

4%

6

3%

Other

11

17%

5

10%

10

9%

26

11%

Total

66

 

48

 

111

 

225

 

Repeated challenge  37

 

Not applicable 13

 

Clarification request 10

 

Total challenges = 285 Total applicable challenges = 225

 

 

Through this exercise we have reviewed the log returned to the Trust.  Around 50% of the challenges are described as agreed, and when the ‘agreed in part’ is added to ‘agreed’, the total is around 65%. 

The largest single category of challenges was requests for a revision to wording and in 47% of the cases this was agreed.  Where there are indisputable inaccuracies, such as typos or data inaccuracy, they are dealt with immediately.  There were 58 challenges of this type (25% of the total), and 34 were upheld, or 15% of the total. 

All challenges which involve data accuracy are included in the ‘data inaccuracy’ figures.  On the factual accuracy log returned to the Trust, we have described these as having been agreed when in reality we may have agreed them in part rather than fully.

It is important to note that none of the changes made by CQC in response to the factual accuracy comments from the Trust were sufficient to lead to a change in the ratings at the subsequent NQAG.

This contrasts with another recent inspection of an NHS hospital trust when, as a result of challenge we agreed to change three of the ratings.  In this case, despite the number of issues raised by the Trust, in NQAG did not feel that there, individually or in aggregate, was sufficient material to change the rating.

Interview with Dr Nik Johnson

I wanted to clarify that the interview with Dr Nik Johnson was a routine interview as part of our inspection process.  We interview many members of staff in the course of our inspections both as part of focus groups and in individual interviews, and where we have particular concerns we will seek to interview people working in that area.  During the inspection at Hinchingbrooke Hospital, we spoke to 246 members of staff through a mix of focus groups and individual interviews.  We had some concerns about paediatric cover in A&E which emerged through the course of our inspection that we needed to follow up with people working in that area.  Dr Johnson is a paediatrician employed by the Trust which has been contracted by Hinchingbrooke to provide paediatric services at the hospital and is based at Hinchingbrooke Hospital.  As such, he was the natural person to follow up those concerns with.

 

 

 

David Behan

Chief Executive

10 February 2015


Annex A: Examples of challenge from the factual accuracy log

Examples of challenges upheld included:

CQC draft

HHCT challenge

Amendment/Response to HHCT

"Patients were routinely triaged within the waiting room area with no consideration for their privacy or dignity."

Propose revision "Patients were routinely triaged within the waiting room area with no consideration for their privacy or dignity. This practice was not in line with departmental expectations; the Trust does provide a private room suitable for triage and expects staff to offer patients a choice."

Amended to state: Patients were routinely triaged within the waiting room area with no consideration for their privacy or dignity. This practice was not in line with departmental expectations; the Trust does provide a private room suitable for triage and expects staff to offer patients a choice.

was so poor that patients were soiling themselves'.

The Trust challenges the accuracy of this statement. As written, it would lead the reader to believe that all patients were soiling themselves. Please define the number of patients for whom this was the case, out of a total number of patients interviewed and the total number of patients admitted to the wards in which this arose as a concern. Please confirm how this was evidenced.

Amended to state “two patients of the 53 we spoke to in the medical and surgical areas stated that they had been told to soil themselves. A further one patient reported that they had soiled themselves whilst awaiting assistance. We brought this to the attention of the Trust and they investigated. However neither CQC nor the Trust could corroborate these claims.” This was evidenced through talking to patients. There was no documentary evidence recorded by nursing staff which either supported or negated these statements. 

We also spoke with 13 patients'.

Propose revision: 'The emergency department sees, on average, just over 100 patients in any given day. During our inspection, we spoke with 13 patients.'

The emergency department sees, on average, just over 100 patients in any given day. During our inspection, we spoke with 13 patients

 

Examples of those challenges that were dismissed include:

CQC draft

HHCT challenge

Amendment/Response to HHCT

The department was planning a renovation… neither staff nor documents could confirm when this was going to happen".

 

Propose revision : "The department was planning a renovation… staff could not confirm when this was going to happen; however, Minutes from the Charitable Funds Committee of May 2014 provide detail and record that it is to be added to the 2015/16 capital plan. The Trust also provided the renovation plan diagram."

We spoke to the operations director and were not offered this evidence as such we cannot consider new evidence provided by the Trust at FAC stage. However the minutes provided do not describe that the committee agreed to finance the plans. Indeed they have requested feedback from the patient experience group prior to approval.

"Since our visit the Trust has put digital locks on all medication doors".

 

Propose rewording: 'Prior to the CQC visit, the Trust had an on-going action plan to implement digital locks Trust wide and these have now been fitted.

There was no evidence supplied or discussed at the time of the inspection or since that this was in progress at the time of the inspection. The only reference we can see relating to locks was on the risk assessment for facilities issues to be reviewed in August 2015. However we have amended the sentence to state: The Trust reported that they were awaiting delivery of digital locks and have replaced all locks with digital lock to ensure security of these areas. The Trust states that these are now in place.  

We were not assured that all staff assessing children were competent to deliver such care".

Propose remove. As noted, the Trust meets the RCN 2013 guidance and, in addition to the liaison and SLA with the provider of children's services that is based on the same site as the Trust, HHCT has a contingent of nurses who are suitably qualified, as evidenced via paediatric competency packs, attendance at CAKES course and PILS training and study day. Triage nurses also are a senior member of the nursing team.

No evidence was submitted during the inspection process to state how many people have attended the CAKES or other courses. The Trust CEO and DoN stated during meetings in October that staff were currently being trained. We spoke with staff during the inspection and they told us that they were not trained in assessing children. We note from new evidence submitted only at FAC stage that training remains ongoing for nursing staff in CAKES and PILS courses.

 

 

 


Account Number:

RQQ

Our reference:

SPL1-1378293871

Provider name:

Hinchingbrooke Healthcare NHS Trust

Provider address:

Hinchingbrooke Hospital

Hinchingbrooke Park

Huntingdon

Cambs

PE29 6NT

For ease of reference, original text copied verbatim from the CQC draft report prefaces the section and has been italicised and put between quotation marks. HHCT’s response then follows.

 

Ref

Page

Report

Section

Suggested Changes with Explanation

CQC decision

CQC comments

1

1

Location report

Ratings

"Overall rating for this trust.... Inadequate. Are services at this trust safe.... Inadequate. Are services at this trust caring.... Inadequate. Are services at this trust well led....Inadequate." 

 

It is the trust’s strong submission that, once the factual inaccuracies have been remedied in the domains of the location report for Hinchingbrooke Health Care NHS Trust, and the wealth of quantitative and qualitative data available to the CQC is included in its considerations, the CQC will be left with residual evidence that contains both characteristics of ‘good’ and “requires improvement’ as set out in the Provider Handbook for NHS acute hospitals. The Trust submits that in the light of the factual accuracy submissions made, there are no reasonable grounds to maintain a rating of ‘inadequate’ for these domains at Hinchingbrooke Health Care NHS Trust. Inspectors of some of the service domains appear to have reached conclusions based predominantly on the limited observations and interviews during of the onsite inspection period without appropriate triangulation and due regard to more detailed relevant data and feedback available to the CQC for the relevant periods. The limited use of the information available to the CQC and the subjectivity demonstrated in certain sections of the report is not in keeping with CQC methodology and undermines its decision on ratings.

Not Agreed

CQC has taken into account all of the relevant evidence in relation to this matter, from all sources, in order to reach a determination on each of the factual accuracy challenges, as set out below in our detailed response. This has resulted in a number of changes to the location report as set out below. The ratings remain as before. See the detailed responses in the body of the document below. Therefore, applying the aggregation principles the ratings the hospital is rated overall as inadequate

2

2

Location report

Letter from the CIH

“the trust management have adopted the 'Circle approach'.

 

Propose revision: 'The Trust's governance is derived from the Franchise Agreement and Intervention Order approved by the Secretary of State for Health (SoSfH).'

Agreed

Amended to state: The Trust's governance is derived from the Franchise Agreement and Intervention Order approved by the Secretary of State for Health.

3

2

Location report

Letter from the CIH

"attended one board meeting' 

 

Propose revision: "attended the Annual Public Meeting [i.e. the Annual General Meeting] on 25 September 2014"

Agreed

Amended to state: attended the Annual Public Meeting [i.e. the Annual General Meeting] on 25 September 2014

4

2

Location report

Letter from the CIH

"There was a lack of paediatric cover within the A&E department, theatres and wards that meant that the care of children in these departments was, at times, unsafe."

 

Propose remove: The trust has not met aspirational targets in respect of paediatric cover but has met national standards. Evidence provided.

Agreed in part

We have checked with our specialists in this field and considered the evidence you have supplied. We have amended to state There was a lack of paediatric cover within the A&E department and theatres that meant that the arrangements for the care of children in these department was, at times, liable to give rise to risks to patient safety.  The RCN guidance, 2003 amended 2013 states that in DGH mixed emergency departments, a minimum of one registered children’s nurse with trauma experience and valid EPLS/APLS training must be available at all times. All other registered nurses caring for children must attain and maintain the minimum knowledge, skills and competence outlined above. As the hospital did not have one registered children’s nurse on at all times in the A&E department the service was liable to give risk to children’s safety. In respect of the operating theatre Surgery for children – delivering a first class service produced by The Royal College of Surgeons of England 2007 states that children in the operating theatre should be cared for by operating department staff that have specific paediatric skills and training. At the time of our inspection sufficient staff did not have these specific skills and training.

5

2

Location report

Letter from the CIH

“predominantly run by hospital consultants from a neighbouring hospital... The trust was still medically led.”

 

Propose revision: Remove 'predominantly run by hospital consultants from a neighbouring hospital' as this was neither recent nor would it be relevant. Amend text in this paragraph to read as 'It is led by a multidisciplinary team of clinical and non-clinical executives partnered with a non-executive Trust Board.'

Agreed in part

Sentence changed to state: It is led by a multidisciplinary team of clinical and non-clinical executives partnered with a non-executive Trust Board. However we found that the trust was predominantly medically led although a new director of nursing had been appointed four months prior to our visit.….”

6

2

Location report

Letter from the CIH

The descriptor 'Trust Development Agency' should be 'Trust Development Authority'. There is inconsistency in this within the report.

Agreed

Amended

7

2

Location report

Letter from the CIH

Walnut Tree Ward' 

 

Propose revision: 'Walnut ward'

Agreed

Amended

8

3

Location report

Letter from the CIH

"Medicines were not always stored or administered appropriately."

 

Propose revision: "IV fluids were not always stored appropriately. Errors and omissions in medications administration were observed on <please state exact number/out of the total number of prescriptions reviewed" in some areas of the trust.

Amend

Amended to state: Medicines were not always stored or administered appropriately in A&E, Juniper ward, Apple Tree ward or Cherry Tree ward.

 

 

9

3

Location report

Letter from the CIH

"Risk assessments, although at times undertaken, were not reflective of the needs of patients in surgery and medical

wards".

 

The Trust challenges the accuracy of this statement and seeks to understand in how many cases this was observed to be the case. As written, it would lead the reader to believe that all patients in surgery and medical wards did not have accurate risk assessments. Whilst the Trust accepts that CQC may have found some risk assessments that were not reflective of changing needs, the Trust disputes that this finding applied to all patients in all of these wards. Please define the number of risk assessments in which this was the case, out of a total number of risk assessments reviewed. Please confirm how this was evidenced.

Clarification

Sentence already amended as below. This was evidenced by review of 46 sets of notes of which 19 were found to have incomplete information or review. This does not affect the comment as it is clear from our evidence that risk assessments were not always completed.

10

3

Location report

Letter from the CIH

"Risk assessments, although at times undertaken, were not reflective of the needs of patients."

 

Propose revision: "Risk assessments were not always reflective of the needs of patients."

Agreed in part

Sentence amended to state: This was evidenced by review of 46 sets of notes of which 19 were found to have incomplete information or review. This does not affect the comment as it is clear from our evidence that risk assessments were not always completed.

11

3

Location report

Letter from the CIH

“Ensure an adequate skill mix in the emergency department, theatres and wards, to ensure that patients of all ages receive a service that meets their needs in a timely manner.

 

Propose remove: The trust has not met aspirational targets in respect of paediatric cover but has met national standards. Evidence provided in respect of skill mix, patient experience and ED performance.

Not agreed

Amended to state: Ensure that the arrangements for the provision of services to children in A&E, operating theatres and outpatients areas provided by the trust, is reviewed to ensure that it meets their needs, and that staff have the appropriate support to raise issues on the service provision. Separate bullet added

Ensure that there are sufficient appropriately skilled nursing staff on medical and surgical wards to meet patients’ needs in a timely manner

12

3

Location report

Letter from the CIH

Ensure pressure ulcer care is provided in accordance with NICE guideline CG179'

 

Propose revision: 'Ensure pressure ulcer care is consistently provided in accordance with NICE guideline CG179.

Agreed

Amended

13

3

Location report

Letter from the CIH

Juniper Wad'

 

Propose revision: 'Juniper ward'

Agreed

Amended

14

3

Location report

Letter from the CIH

was so poor that patients were soiling themselves'.

 

The Trust challenges the accuracy of this statement. As written, it would lead the reader to believe that all patients were soiling themselves. Please define the number of patients for whom this was the case, out of a total number of patients interviewed and the total number of patients admitted to the wards in which this arose as a concern. Please confirm how this was evidenced.

In part

 

Amended to state “two patients of the 53 we spoke to in the medical and surgical areas stated that they had been told to soil themselves. A further one patient reported that they had soiled themselves whilst awaiting assistance. We brought this to the attention of the trust and they investigated. However neither CQC nor the trust could corroborate these claims.” This was evidenced through talking to patients. There was no documentary evidence recorded by nursing staff which either supported or negated these statements. 

15

3

Location report

 Letter from the CIH

"Disseminate the lessons learnt from incidents to ensure that quality of care for patients is improved."

 

Propose revision: " Standardise and improve the dissemination of lessons learnt from incidents to support the improvement of the provision of high quality care for all patients."

Agreed

Amended to state: Standardise and improve the dissemination of lessons learnt from incidents to support the improvement of the provision of high quality care for all patients.

16

4

Location report

Letter from the CIH

Ensure that all patients receive timely referral to the palliative care service.'

 

Propose revision: 'Ensure that all appropriate patients receive timely referral to the palliative care service.'

Agreed

Amended to state: Ensure that all appropriate patients receive timely referral to the palliative care service.

17

4

Location report

Letter from the CIH

Take action to ensure that when pre-alert telephone calls are received by the A&E department, action is taken to ensure a timely response.'

 

Propose remove: As evidence on page 20 of the location report evidences, concerns were not raised in respect of this: "We looked at a pre-alert form with regards to a pre-alert that occurred during our inspection, and found that the forms had been completed fully, with any clinical observations recorded, estimated time of arrival of the ambulance to the accident and emergency department, and details of who took the information over the telephone from the ambulance service."

Agreed

Removed

18

pp 5-9

Location report

Summary of findings all services

Please cross reference with the specific points raised in the Location and Provider reports and ensure that accepted corrections and revisions are applied to these summaries.

 

Done

19

pp 10-11

Location report

Background

Please cross reference with comment relating to Page 2 of the provider report. The Trust has not adopted the ‘Circle Approach’ for governance the governance is derived from the Franchise Agreement and Intervention Order approved by the SOSfH.

 

Done

20

12

Location report

Detailed findings - Safe/ Effective/ Caring

Please correct and contextualise data as follows: 'The Trust has an ‘All Diagnosis’ SMR of 77.06 - significantly ‘lower than expected’ <Dr Foster data for August 2013 - July 2014>. The Trust had a Serious Incident rate of 41 in the period incorrectly stated by the CQC to be 102 [as highlighted in response to inaccuracies in the CQC Data Pack pre inspection], it is highly placed in the middle group of small acute hospital reporters to NRLS, with a low rate of patient accidents compared with other small acute trusts, and a 96.8% rate of no/low harm incidents, indicating a positive reporting culture and low risk of harm.

 

Amended as per Provider report FAC

21

15

Urgent and emergency services

 

'Safe…..Inadequate'.

 

Propose revision: 'Safe….. Requires improvement'. The CQC is referred to the submissions made in this document on the key question of “Are urgent and emergency services safe” at Hinchingbrooke Health Care NHS Trust? The trust looks forward to receiving the CQC’s response to the points raised in this document in accordance with the CQC’s factual accuracy procedure.  It is the trust’s strong submission that, once the factual inaccuracies have been remedied in the report for Urgent and Emergency services at Hinchingbrooke Health Care NHS Trust, and the wealth of quantitative and qualitative data available to the CQC is included, the CQC will be left with residual evidence in both of these domains which contains both characteristics of ‘good’ and “requires improvement’ as set out in the Provider Handbook for NHS acute hospitals. The Trust submits that in the light of the factual accuracy submissions made, there are no reasonable grounds to maintain a rating of ‘inadequate’ for ‘safe’ in Urgent and Emergency services  at Hinchingbrooke Health Care NHS Trust. Inspectors of this domain appear to have reached their conclusion based predominantly on the limited observations and interviews during of the onsite inspection period without appropriate triangulation and due regard to more detailed relevant data and feedback available to the CQC for the relevant periods. The limited use of the information available to the CQC and the subjectivity demonstrated in this section of the report is not in keeping with CQC methodology and undermines its decision on ratings.

Not agreed

The rating of Inadequate for Safety in relation to urgent and emergency services remains. The reasons for this decision are based on the fact that the hospital meets one or more of the criteria for  an inadequate rating namely:

  • Patient safety incidents are not always identified and reported and/or processes to review and learn from incidents are inadequate, increasing the risk of repeat occurrences or more serious harm in the future.
  • Staffing levels show substantial or frequent shortages or inappropriate staff mix which may compromise safety or effectiveness, or may results in use of inappropriate use of restrictive practices. Over-reliance on agency or locum staff creates risks to safety.

This relates to the low incident reporting in the ED (4%) and subsequent lack of learning, the lack of paediatric nurses available to cover the 24 hour period in ED, the vacancy factor within ED (26%), the management of the staff available within the department to meet the needs of patients.

22

15

Urgent and emergency services

 

Well led…..Inadequate'.

 

Propose revision: 'Well led….. Requires improvement'. The CQC is referred to the submissions made in this document on the key question of “Are urgent and emergency services well led” at Hinchingbrooke Health Care NHS Trust? The trust looks forward to receiving the CQC’s response to the points raised in this document in accordance with the CQC’s factual accuracy procedure.  t is the trust’s strong submission that, once the factual inaccuracies have been remedied in the report for Urgent and Emergency services at Hinchingbrooke Health Care NHS Trust, and the wealth of quantative and qualitative data available to the CQC is included, the CQC will be left with residual evidence in both of these domains which contains both characteristics of ‘good’ and “requires improvement’ as set out in the Provider Handbook for NHS acute hospitals. The Trust submits that in the light of the factual accuracy submissions made, there are no reasonable grounds to maintain a rating of ‘inadequate’ for ‘well led’ in Urgent and Emergency services  at Hinchingbrooke Health Care NHS Trust.Inspectors of this domain appear to have reached their conclusion based predominantly on the limited observations and interviews during of the onsite inspection period without appropriate triangulation and due regard to more detailed relevant data and feedback available to the CQC for the relevant periods. The limited use of the information available to the CQC and the subjectivity demonstrated in this section of the report is not in keeping with CQC methodology and undermines its decision on ratings.

Not agreed

The rating of Inadequate for Well Led in relation to urgent and emergency services remains. The reasons for this decision are based on the fact that the hospital meets one or more of the criteria for  an inadequate rating namely:

  • There is no clear vision and guiding values
  • Staff and departments across the organisation do not have clear objectives. Team work is poorly developed and implemented with lack of clarity about team tasks, objectives, membership, roles. There is poor collaboration and cooperation between teams and departments and there are high levels of conflict.
  • The governance arrangements and their purpose is unclear. There is no process in place to review key items such as the strategy, values, objectives, plans or the governance framework.

This relates to the limited understanding within the department as to the vision , objectives and priorities for the service even at a senior level within the department, the limited improvement as a result of incidents, the lack of leadership within the department as there is no senior leader, the failure to manage staff to meet the demands of patient flows.

 

 

23

15

Urgent and emergency services

 

The emergency department at Hinchingbrooke Hospital was inadequate in respect of the safe and well led domains'.

 

Propose revision: 'The emergency department at Hinchingbrooke Hospital required improvement in respect of the safe and well led domains'. It is the trust’s strong submission that, once the factual inaccuracies have been remedied in the report for Urgent and Emergency services at Hinchingbrooke Health Care NHS Trust, and the wealth of quantitative and qualitative data available to the CQC is included, the CQC will be left with residual evidence in both of these domains which contains both characteristics of ‘good’ and “requires improvement’ as set out in the Provider Handbook for NHS acute hospitals. The Trust submits that in the light of the factual accuracy submissions made, there are no reasonable grounds to maintain a rating of ‘inadequate’ for ‘safe and well led’ domains in Urgent and Emergency services  at Hinchingbrooke Health Care NHS Trust. Inspectors of this domain appear to have reached their conclusion based predominantly on the limited observations and interviews during of the onsite inspection period without appropriate triangulation and due regard to more detailed relevant data and feedback available to the CQC for the relevant periods. The limited use of the information available to the CQC and the subjectivity demonstrated in this section of the report is not in keeping with CQC methodology and undermines its decision on ratings.

Not agreed

As out lined in comments 21 and 22 the judgement has not been changed therefore this has not been amended.

Urgent and emergency services overall

These are relevant facts and the trust considers their omission an inaccuracy:

  • We met the 95% 4-hour waiting time target consistently in 2013/14, ranked in the top 10 nationally; and this year, have only missed the target in recent months as a result of pressures across our Clinical Commissioning Group.
  • The CQC also commissioned a report by Picker on Accident and Emergency care in 2014. It found that Hinchingbrooke rated highly in numerous aspects, including privacy and dignity, environment, waiting times and pain control. Most strikingly, we scored 9/10 for overall patient experience.

 

 

We have taken this information into account and have added:

  • Report in the responsive domain states: On average, the trust maintains the 95% target of assessment of people within four hours of arriving in the emergency department. There have been seven occasions of breaching the 95% target between April 2013 and April 2014. Prior to the week of our inspection, the trust achieved 86.5% of patients seen within 4 hours.
  • Report in the caring domain states that the comment cards were mainly negative but the following bullet states: The national A&E patient survey commissioned by the CQC, which had a trust response rate of 35% compared with a national response rate of 34% and that was responded to by 293 patients who had used the trust's emergency department services, contradicts our comment card findings, with patients scoring the trust at 9/10 for patients feeling they were treated with dignity and respect, an increase from 8.5/10 in 2012.

Both these points were already in the report and have been amended as per FAC response.

24

x

Urgent and emergency services

 

"Patients were routinely triaged within the waiting room area with no consideration for their privacy or dignity."

 

Propose revision: "Patients were routinely triaged within the waiting room area with no consideration for their privacy or dignity. This practice was not in line with departmental expectations; the Trust does provide a private room suitable for triage and expects staff to offer patients a choice."

Agreed

Amended to state: Patients were routinely triaged within the waiting room area with no consideration for their privacy or dignity. This practice was not in line with departmental expectations; the Trust does provide a private room suitable for triage and expects staff to offer patients a choice.

25

x

Urgent and emergency services

 

"We looked at equipment which was visibly clean, but found that some equipment was not maintained to the manufacturer’s recommendations with service labels highlighting that a service was due."

 

Propose revision: "We looked at equipment which was visibly clean, The Trust achieves a 94% compliance rate in respect of servicing of equipment. The Trust has in the past experienced some issues when service labels were attached to the lead, rather than to the main body of the equipment, but this practice has been amended."

Evidence provided: database extract containing service schedule statistics, plus pivot table extracted from <DR55 20140917 TOTAL INCIDENTS FROM APRIL 2013 TO CURRENT>, supplied to CQC on 19/09/2014

Agreed in part.

Statement amended to We looked at equipment which was visibly clean but found that some equipment did not have maintenance labels attached to it. The trust provided a schedule of maintenance and we could see that 94% of equipment had in fact been maintained. The trust stated that there had been previous issues with labels being incorrectly applied to the lead of the equipment rather than the main body. The trust has reported that this practice has now been amended.  Whilst this schedule shows equipment to be serviced the inspectors found that at least 12 pieces of patient assessment equipment, such as defibrillators and blood pressure monitoring equipment, did not have the date of the last PAT test or servicing and that some had stickers which stated when the last test was undertaken and some when the next test was due.

26

15

Urgent and emergency services

 

…the provision of care was not assured by the leadership, governance or culture in place during our inspection'.

 

Propose revision: '… the provision of care at the time of our observation did not fully demonstrate the level of assurance that is expected; however, outcomes data and patient survey findings demonstrate that the safety of patients and their experience of care are, at minimum, in line with those of most other NHS trusts, with no negative outlier concerns.'

Not agreed

This sentence describes the issues around leadership of the department rather than clinical outcomes. The summary reflects the issues raised in the well led section of the report. However the sentence has been amended to state: Clinical outcomes and monitoring of the service showed that the trust was not outliers when compared to others however we found that the provision of care was not assured by the leadership, governance or culture in place during our inspection.

27

15

Urgent and emergency services

 

…we spoke with clinical and nursing leads…'

 

Propose revision: '…we spoke with clinical leads from medical and nursing disciplines'. Medical and nursing staff are both 'clinical'.

Agreed

Amended to state: we spoke with clinical leads from medical and nursing disciplines for the department.

28

15

Urgent and emergency services

 

“Paediatric cover for children in this department was not sufficient to cover 24 hours and staff did not have the competency to care for children when paediatric nurses were not on duty.”

 

Propose remove: The Royal College of Nursing 2013 guidance states: "In DGH mixed emergency departments, a minimum of one registered children’s nurse with trauma experience and valid EPLS/APLS training must be available at all times (RCN and RCPCH 2010; RCPCH, 2012).... to assist, supervise, support and chaperone children (DH, 1991; RCN, 2011)." HHCT achieves this through its own trained staff contingent and through liaison and a formal SLA with another provider operating children's services from within the same hospital site. HHCT does not operate a trauma centre; we are served by the Regional Trauma Network and CUH is the receiving hospital.

Not agreed

As outlined above in factual accuracy comment number 4 Therefore we have made the judgement that staffing levels show substantial or frequent shortages or inappropriate staff mix which may compromise safety or effectiveness, or may results in use of inappropriate use of restrictive practices.

29

15

Urgent and emergency services

 

“We also spoke with 13 patients'.

 

Propose revision: 'The emergency department sees, on average, just over 100 patients in any given day. During our inspection, we spoke with 13 patients.'

Agreed

Amended to state: The emergency department sees, on average, just over 100 patients in any given day. During our inspection, we spoke with 13 patients

30

16

Urgent and emergency services

 

"Staff told us that they did not report incidents via hospital reporting system….time to complete report….(no) feedback on outcomes and closure on incidents".

 

Propose addition to wording: 'The incident data supplied to the CQC during inspection shows that the emergency care centre reported 256 incidents since April 2013, accounting for only 4% of the total incidents reported. Staff indicated that this low level of reporting reflected the amount of time it took to complete reports and the limited feedback on outcomes or closure of reported incidents. The Trust has invested in an improved, web-based incident reporting system in recognition of the limitations of the system currently in use throughout the trust. Since our inspection, the Trust has appointed a Director of Governance and Risk to drive further improvement in these areas.'

Agreed in part

Amended the sentence to state:  We asked staff directly if they reported incidents and had knowledge of the reporting system. The incident data supplied to the CQC during inspection shows that the emergency care centre reported 256 incidents since April 2013, accounting for only 4% of the total incidents reported. Staff indicated that this low level of reporting reflected the amount of time it took to complete reports and the limited feedback on outcomes or closure of reported incidents.

31

16

Urgent and emergency services

 

"Staff when busy were tolerant of a lower standard of care". Propose reword: "When busy, staff appeared to inspectors to be tolerant of a lower standard of care; however, the trust did supply evidence to demonstrate that incident reports were submitted in relation to insufficient numbers or skill mix of staff when this occurred."

In part

Sentence amended to state: When busy, two staff told inspectors that they accepted that they could not give the care that they would wish to do so. We heard one patient request assistance and a member of staff told them that they did not have time but would return. However after 30 minutes the patient stated that no one had returned. We raised this issue to a member of staff who assisted the patient.

32

17

Urgent and emergency services

 

"...we observed limited personal protective equipment and hand hygiene practices in place."

 

Propose revision: "...we observed limited personal protective equipment and hand hygiene practices in place; however, evidence provided by the trust demonstrates a high level of compliance with hand hygiene practices across a number of months, as observed during Handwashing Audits."

Agreed

Sentence amended to state: , Evidence provided by the trust demonstrated a high level of compliance with hand hygiene practices across a number of months, as observed during hand washing audits, however we observed limited personal protective equipment and hand hygiene practices in use during our inspection.

 

33

17

Urgent and emergency services

 

"Children's A&E services were not using a safety thermometer".

 

Propose remove: guidance on the NHS safety thermometer website states that The NHS Safety Thermometer "Classic" allows teams to measure harm and the proportion of patients that are 'harm free' from pressure ulcers, falls, urine infections (in patients with a catheter) and venous thromboembolism during their working day, for example at shift handover or during ward rounds.This demonstrates that the tool is not appropriate for use in children's A&E services, so the statement made gives a negative commentary without due cause to do so.

Agreed

Sentence removed

34

17

Urgent and emergency services

 

"The department was planning a renovation… neither staff nor documents could confirm when this was going to happen".

 

Propose revision : "The department was planning a renovation… staff could not confirm when this was going to happen; however, Minutes from the Charitable Funds Committee of May 2014 provide detail and record that it is to be added to the 2015/16 capital plan. The Trust also provided the renovation plan diagram."

Not Agreed

We spoke to the operations director and were not offered this evidence as such we cannot consider new evidence provided by the trust at FAC stage. However the minutes provided do not describe that the committee agreed to finance the plans. Indeed they have requested feedback from the patient experience group prior to approval.

35

17

Urgent and emergency services

 

"We did not see that treatment rooms were deep cleaned".

 

Propose removing this comment from the report or amending to 'During the period of our observations we did not witness a deep clean of the treatment rooms; however, the Trust supplied evidence of cleans and did not, at the time of our visit, have infectious patients through this area to trigger a deep clean."

Agreed in part

Sentence amended to say:  we did not see treatment rooms routinely cleaned between patients.

 

36

17

Urgent and emergency services

 

"We looked at various pieces of equipment across all areas within the A&E department. We found inconsistency with regards to scheduled servicing, with some pieces of equipment being a year out of date from the recommended service. This was identified through the trusts internal service stickers on each piece of equipment."

 

Propose revision: "The Trust achieves a 94% compliance rate in respect of servicing of equipment. The Trust has in the past experienced some issues when service labels were attached to the lead, rather than to the main body of the equipment, but this practice has been amended."

Agreed in part

Amended as above in comment 25

37

18

Urgent and emergency services

 

"Since our visit the trust have put digital locks on all medication doors".

 

Propose rewording: 'Prior to the CQC visit, the trust had an on-going action plan to implement digital locks trust wide and these have now been fitted.

Not Agreed

There was no evidence supplied or discussed at the time of the inspection or since that this was in progress at the time of the inspection. The only reference we can see relating to locks was on the risk assessment for facilities issues to be reviewed in August 2015.However we have amended the sentence to state: The trust reported that they were awaiting delivery of digital locks and have replaced all locks with digital lock to ensure security of these areas. The trust states that these are now in place.  

38

18

Urgent and emergency services

 

"We found the controlled drug cupboard open".

 

Propose revision: "We found that the outer door of the cupboard housing the locked controlled drug cupboard could be opened; the controlled drug cupboard and medicines remained secure but this potentially allowed access to the controlled drug book, which could enable tampering with the documentation confirming the issue of controlled drugs." This point is actually made two paragraphs down within the CQC draft report, where it confirms that it was the additional outer cupboard door that could be opened, not the inner controlled drug cupboard.

Agreed

Amended to state: We found that the outer door of the cupboard housing the locked controlled drug cupboard could be opened; the controlled drug cupboard and medicines remained secure but this potentially allowed access to the controlled drug book, which could enable tampering with the documentation confirming the issue of controlled drugs. Therefore medicines were inappropriately stored.  We also found the drug fridge within the resuscitation area unlocked which contained a selection of muscle relaxants.

39

19

Urgent and emergency services

 

"Children were not always seen by a suitably qualified nurse".

 

Propose remove: As noted, the Trust meets the RCN 2013 guidance and, in addition to the liaison and SLA with CCS, which provides children's services from within the same site, HHCT has a contingent of nurses who are suitably qualified, as evidenced via paediatric competency packs, attendance at CAKES course and PILS training and study day. Triage nurses are senior members of the nursing team. The documentation within children's records were noted elsewhere in this report by CQC inspectors to be of a high standard, with a holistic assessment of need. This would not be the case if staff were unsuitably qualified.

Not agreed

See above comment 4

40

19

Urgent and emergency services

 

"Lack of senior paediatric presence in the A&E department meant that this issue was not managed effectively".

 

Propose remove: This has not been evidenced. Contradictory evidence has been provided via related challenge points.

Not agreed

The sister in the ED did not feel sufficiently authorised to challenge the availability of the CAMHS team. The risk summit highlighted that when this was brought to a senior level, action was taken to address this issue.

41

19

Urgent and emergency services

 

"One child waited 19 hours to be seen by the CAMHS in the department. Staff told us that the children's ward in the hospital refused to accept children who were deemed at high risk of mental health concerns until a thorough CAMHS assessment had taken place". Propose change:  'One child waited 19 hours to be seen by CAMHS in the department. CAMHS services are not provided by Hinchingbrooke Health Care NHS Trust but are provided by an external agency. Whilst in the department, the child was looked after by a paediatric trained nurse, with risk assessment and full escalation, throughout the child's stay in the emergency department, to Director level. The ED consultant and consultant on call paediatrician were involved, with Director to Director escalation and collaboration with colleagues from the children's services' provider operating from the same site as HHCT. A report was written and provided to the CAMH team for their investigation. Staff told us that the children's services' provider operating on the same site as the trust cannot accept admission of children with a high risk of mental health issues until a thorough CAMHS assessment has taken place. CAMHS delays are a recognised issue across the region, and this is discussed at the combined safeguarding paediatric clinical governance meetings.

 

The trust believes that this event could hardly have had more senior input and was investigated fully. The Trust questions the level of triangulation with HHCT and CCS/CAMH clinicians undertaken by the inspectors before forming this view.

Agreed

Amended to state: The trust stated that one child had waited 19 hours to be seen by the CAMHS in the department. The trust ensured that the safety needs of the child had been met during this time through appropriate escalation and actions taken. However the trust needs to work in partnership with local partners to address children’s mental health needs. CAMHS delays are a recognised issue across the region, and this is discussed at the combined safeguarding paediatric clinical governance meetings.

 

42

19

Urgent and emergency services

 

"Records confirmed that at times the department was seeing a high number of paediatric attendances with a history of self-harm".

 

Propose remove: The Trust challenges both the accuracy and relevance of this statement. As noted elsewhere in the report, 13 children with a history of self-harm had presented to the ED in 2014. This is on a background of almost 500 paediatric attendances in the same period. There is no evidence to support the inference that this level of attendance introduces a risk to their immediate safety or longer term outcomes.

Not agreed

The bullet point states Records confirmed that at times the department was seeing a high number of paediatric attendances with a history of self-harm. For example in 2013, 94 children attended the department with a history of self-harm, and in 2014 to date, there have been 13 attendances.

43

19

Urgent and emergency services

 

"We raised these concerns to the trust board who took action in employing temporary staff in the department to ensure that children were effective for children".

 

Propose remove: the comment is an inaccurate reflection of events and also contains a typographical error. The trust has employed additional qualified paediatric nurses whilst considering its response to the allegation made by CQC inspectors that the trust was not meeting national standards. This allegation was incorrect; the trust did not meet aspirational targets but did meet the actual required national standard.

In part

Typographical error amended. This is a statement of fact and is reported so as to reflect the action taken by the trust. However sentence amended to state: We raised these concerns to the trust who took action in temporarily employing additional qualified paediatric nurses in the department. This sentence has been moved to staffing to which it relates rather than the CAMHS service

44

20

Urgent and emergency services

 

"The current vacancy percentage across emergency division at the trust is 26%".

 

Propose revision: This should read 'department' and not 'division'.

Agreed

Amended

45

20

Urgent and emergency services

 

"The Royal College of Nursing 2013 guidance advises there must be a minimum of 1 registered children's nurse available at all times in emergency departments"

 

Propose revision: "The Royal College of Nursing 2013 guidance states that In DGH mixed emergency departments, a minimum of one registered children’s nurse with trauma experience and valid EPLS/APLS training must be available at all times (RCN and RCPCH 2010; RCPCH, 2012).... to assist, supervise, support and chaperone children (DH, 1991; RCN, 2011). HHCT achieves this through its own trained staff contingent and through liaison and SLA with CCS, which operates children's services from within the same hospital site. The trust does not run a trauma service and this is provided by the Regional Trauma Network, with a Cambridge Hospital acting as the receiving unit.”

Not agreed

As above in comment 4

46

20

Urgent and emergency services

 

"We observed that children were frequently waiting more than 15 mins to be assessed".

 

The Trust requests that the actual number of children observed waiting within the department during the period of observation and the actual number of children not assessed within 15 minutes is provided to us for factual accuracy checking.

 

If the statement proves to be factually correct, then the Trust proposes the following revision:

"During the period of our observation we observed that children were frequently waiting more than 15 minutes to be assessed; however, paediatric audits undertaken during February and June 2014, received from the Trust, demonstrated a 99.1% average rate for children receiving assessment within 15 minutes."

Agreed

Sentence removed bullet now states Paediatric audits received from the trust show that 99% of children receive an assessment within the target of 15 minutes. However during our inspection parents told us that the service needs “a separate A&E for children”, and that “the waiting time in this department [for children] is unacceptable”. During our inspection we observed that one child waiting more than 15 minutes to be assessed; this was a very unwell child who required prompt assessment. We immediately bought this to the manager’s attention, and appropriate action was taken.

47

20

Urgent and emergency services

 

"We were not assured that all staff assessing children were competent to deliver such care".

 

Propose remove. As noted, the Trust meets the RCN 2013 guidance and, in addition to the liaison and SLA with the provider of children's services that is based on the same site as the Trust, HHCT has a contingent of nurses who are suitably qualified, as evidenced via paediatric competency packs, attendance at CAKES course and PILS training and study day. Triage nurses also are a senior member of the nursing team.

Not Agreed

See above comment 4. No evidence was submitted during the inspection process to state how many people have attended the CAKES or other courses. The trust CEO and DoN stated during meetings in October that staff were currently being trained. We spoke with staff during the inspection and they told us that they were not trained in assessing children. We note from new evidence submitted only at FAC stage that training remains ongoing for nursing staff in CAKES and PILS courses.

48

21

Urgent and emergency services

 

"During our inspection we did not see any intentional rounding taking place within the emergency department".

 

Propose remove: Intentional rounding did take place and this is corroborated by the CQC on page 18 of the draft document, where it states: "We observed that intentional rounds took place by nursing staff".

Clarification

We observed that intentional rounding took place in the Acute Admissions Unit but not in the ED.

49

21

Urgent and emergency services

 

"We did not witness any checks that food and drink were offered".

 

Propose rewording: “During the period of our observation, we did not witness checks that food and drink had been offered; however, this is included within intential rounding, which operates throughout the trust and was observed by inspectors to be carried out in the emergency department."

Not agreed

Within the AAU the intentional round we saw taking place was in respect of undertaking observations no checks in respect of food and drink were made.

50

22

Urgent and emergency services

 

"...staff were overstretched due to poor organisation"

 

Propose remove: The CQC has provided no evidence in support of this subjective opinion. The nurse lead was the organiser of the team and was on site and managing the team. The department was busy but allocation of resource was not poorly organised.

Agreed in part

Sentence amended to state:

We saw patients getting frustrated that they were waiting extended periods for treatment and lack of information; however staff reported that they wished they had more time to care.

51

22

Urgent and emergency services

 

"We found that children's nutrition and hydration needs were not always met, due to a lack of paediatric 'fast-track' service and long waits seen in the department".

 

Propose remove: The CQC has not provided the evidence of 'long waits seen in the department' with the numbers or lengths of wait to enable the Trust in undertake a factual accuracy check. The trust's electronic recording system evidences wait times that are not excessive. Evidence provided.

Agreed

Sentence amended to state: We found that children's nutrition and hydration needs were not always met.

 

52

22

Urgent and emergency services

 

"We received a number of comment cards from this department which highlighted that patients were not always treated with respect or sometimes believed when receiving treatment".

 

Proposed revision: "We received a number of comment cards from this department. In <please provide number of cards> comments indicated that patients were not always treated with respect and in <please provide number of cards> or sometimes believed when receiving treatment; however, Friends and Family feedback and the national A&E patient survey commissioned by the CQC contradicts this." The Trust publishes all of its patient feedback reports, whether positive or negative, and can evidence overwhelmingly positive feedback - publications can all be found via: http://www.hinchingbrooke.nhs.uk/page/patients-and-visitors/patient-feedback   A&E patient survey evidence.

In part

Amended to state: We received 17 comment cards from this department. Twelve comments indicated that patients were not always treated with respect and in one stated that they were not believed when receiving treatment; however, Friends and Family feedback and the national A&E patient survey commissioned by the CQC contradicts this finding.

53

23

Urgent and emergency services

 

"Out of 17 comment cards completed by patients during our inspection 16 contained negative comments."

 

Would the CQC inform the trust how many positive comments were included in these comment cards alongside the negative comments? As noted previously in this section of the report, the trust's performance in the family and friends test s better than the average for accident and emergency departments, and national A&E patient survey shows no negative outlier for any question, indicating some anomaly with findings during the visit.

Clarification

Only one contained a positive comment. Two cards contained information which caused such concern that they were copied and left on the DoN’s desk. The Head of Hospital Inspection informed her that we would contact patients should she wish further information. We were not requested to contact these patients.

54

23

Urgent and emergency services

 

"Significant number of people who left the department before being seen".

 

Propose removal: The CQC has not evidenced the number or rate of waiting patients who left the department before being seen. The Trust has provided evidence that demonstrates that HHCT waiting times are significantly below the national average. The Trust's four hour waiting times' performance in July 2014 fell to 92.9%; its first monthly drop below a 95% achievement. Rolling 12 month figure at time of inspection was 95.6%, which compares favourably with other NHS trusts and is not indicative of a poorly managed service. Performance data provided.

In part

The data pack demonstrates the percentage of patients leaving the ED without being seen is above the national average. This shows a general increase in the trend of patients leaving the department before being seen. Sentence amended to state: There were a higher than the England average number of people who left the department before being seen

55

23

Urgent and emergency services

 

"The department arranged the nursing staff into teams that looked after specific areas…. Patients may wait for a longer period, as nurses are not moved around".

 

Propose rewording: "As is common in many emergency departments, nursing staff are organised into teams that look after specific areas. This practice can lead to longer waiting periods if staff are not moved flexibly in accordance to need; however, inspectors saw no evidence of this during their observation period. "

Not agreed

Inspectors saw and heard that staff were not moved around to meet patient need. This was in part due to the skill mix within the department.

56

23

Urgent and emergency services

 

"There was limited information available to support people during a time of bereavement, and also taking into account religious and cultural needs".

 

Propose removal: The Trust's Chaplaincy service has been hugely recognised and commended throughout the draft report. This comment is a contradiction.

Not agreed

Whilst the chaplaincy team were very good there was little information available within the ED on bereavement which took into account religious and cultural needs. This should be available for relatives when the chaplaincy service was unavailable.

57

23

Urgent and emergency services

 

"We saw some significant concerns about the lack of compassionate care. One patient was told that the staff and department had one rule that 'patients lie.'"

 

Propose revision: "We saw <please provide exact number of> significant concerns about the lack of compassionate care versus exact number of care interactions witnessed. One patient told us that the staff and department had one rule, 'that patients lie'.  The national A&E patient survey commissioned by the CQC, which had a trust response rate of 35% compared with a national response rate of 34% and that was responded to by 293 patients who had used the trust's emergency department services, contradicts this, with patients scoring the trust at 9/10 for patients feeling they were treated with dignity and respect, an increase from 8.5/10 in 2012." The Trust cannot contest that this statement was made by a patient to the inspector; however, the allegation made cannot be substantiated and staff absolutely refute any suggestion that they would say this. The Trust queries the circumstances of the patient when they alleged this and also queries why the staff on duty in the ED were not informed of this and offered an immediate right of reply.  Friends and Family feedback testimony for HHCT and the CQC's own A&E patient survey contradict the negative views expressed here in respect of lack of compassion. The Trust publishes all of its patient feedback reports, whether positive or negative, and can evidence overwhelmingly positive feedback - publications can all be found via: http://www.hinchingbrooke.nhs.uk/page/patients-and-visitors/patient-feedback

Not agreed

The HHI did copy this patient’s comment card and left it for the DoN. The Head of Hospital Inspection spoke about these cards and it was suggested to the DoN that should she require further information CQC would contact this patient to agree handover of this patient’s information. This was never requested.  However in order to provide a balanced view we have removed the last part of the sentence and added in a bullet point stating that: The national A&E patient survey commissioned by the CQC, which had a trust response rate of 35% compared with a national response rate of 34% and that was responded to by 293 patients who had used the trust's emergency department services, contradicts our comment card findings, with patients scoring the trust at 9/10 for patients feeling they were treated with dignity and respect, an increase from 8.5/10 in 2012.

58

24

Urgent and emergency services

 

"(information leaflets) not available in all of the main languages spoken in the community". The Trust challenges this statement and would ask for clarification on which specific 'main languages' are believed to be spoken in the community. As noted elsewhere in the document, Cambridgeshire has a low ethnic minority level of around 5%, meaning that other spoken languages can be diverse and at low levels. There is a balance needed to be struck between supporting patients with written information and not spending limited resources on materials that will only rarely be used. As noted, full translation services are available throughout the trust and we believe this to be a correct judgment of use of resources.

Agree

Amended to state:

There were no information leaflets available for many different minor injuries. Those that were provided were available in English.

We found at our inspection that leaflet racks were almost empty and therefore patients were not assisted in making decisions about their care and treatment in this manner.

59

24

Urgent and emergency services

 

"No translation service was available for those patients whose first language was not English. Within the department it was not possible to request a translator. The staff told us that they would usually use other staff members to translate".

 

Propose removal: this statement is factually incorrect; HHCT offers a full translation service, as was recognised elsewhere in the CQC draft report. The CQC has not provided evidence to say how it concluded that it was not possible to request a translator. If a member of staff on duty within the department has the language proficiency required to translate for any particular patient, then it is correct to say that they would usually be asked to do so; however, the trust does not place reliance on this being available and can, and does, offer translation services throughout all clinical areas.

Agreed in part

Sentence amended to state: Staff we spoke with were unaware of the translation service available for those patients whose first language was not English. Within the department we were told by staff that it was not possible to request a translator. The staff we spoke with told us that they would usually use other staff members to translate.

60

24

Urgent and emergency services

 

"There were no information leaflets available for many different minor injuries".

 

Propose remove: This is factually incorrect; there are leaflets available for a range of minor injuries, with a rack for information leaflets placed within the waiting area. The CQC has not provided evidence of what it means by 'many different minor injuries'.

Not agreed

Whilst some information leaflets were available during our inspection we saw only five different injuries described in leaflets. We noted that the leaflet racks were almost empty on both days.

61

25

Urgent and emergency services

 

"Acceptance of a lower standard of care due to pressure". .

 

Propose removal: Whilst recognising that, at times of severe pressure, high quality patient experiences may be compromised due to longer waiting times, the Trust has not demonstrated an 'acceptance' of this position. The CQC's own national A&E patient survey evidences that the trust is not an outlier on any element of patient experience and there is no evidence to suggest that outcomes for the patients are poor or that peaks in pressure lead to harm. Evidence provided by way of pivot table extracted from data supplied to the CQC on 19 September and reference to the National A&E Patient Survey.

Not Agreed

We are not stating in this area that the trust has demonstrated an acceptance of this position. The paragraph describes the staff’s acceptance that they cannot always deliver the level of care that they would like to give the pressures on them. We spoke with 13 clinical staff and over half of them expressed the desire to be able to give a better level of care at all times. Whilst the trust performs on average in the A&E survey. This paragraph describes how the staff had a low morale because they were resigned to the fact that at times when the department was busy they could not provide the care that they would wish to provide. There is also a leadership responsibility to ensure that there are enough staff and that these are organised in a manner which ensures that care meets the patients’ needs.

62

25

Urgent and emergency services

 

"Decision was made... not replace other managers but to assign their workload within an understaffed department"

 

Please refer to provided evidence demonstrating that management replacement took place.

Agreed

Thank you for the evidence.  Despite not highlighting when the decision was made to appoint to the post of operations manager we have removed this part of the sentence.

63

25

Urgent and emergency services

 

"Staff told us they were not provided with updates or amendments on to the departments priorities and performance".

 

Propose revision:  "Staff told us they were not provided with updates or amendments on to the department's priorities and performance; however, the Trust provided evidence of staff newsletters containing this information." Evidence of this is provided.

Agreed

Sentence amended to state: Staff told us that they were not aware of updates or amendments on the department’s priorities and performance. We cannot accept evidence at the FAC stage unless it fulfils the criteria set out in our policy.

64

25

Urgent and emergency services

 

"The future vision of the accident and emergency department was not embedded within the team".

 

Propose remove: It is not unreasonable to find that members of the team were not fully cogniscent of the proposed layout and timeline for renovation. As inspectors are aware, there has been considerable investment in renovations across the Trust to improve the facilities inherited when the Circle franchise commenced in 2012. The trust has demonstrated an ability to undertake significant renovation and rebuild, which is not indicative of an organisation that cannot plan and execute needed environmental improvements. It is wholly reasonable that the trust has prioritised the renovation and rebuild of areas that posed significant risk to patients, staff and visitors ahead of the ED, which, whilst not ideal in layout, is not unsafe, unsightly or unclean.

Not agreed

Whilst staff were unaware of the renovations which had yet to be signed off (evidence provided by trust) staff did not have a sense of a vision or an understanding of the objectives and priorities for the unit. This included an interview with the director of operations for the unit. At a service level we are seeking to assess how well led the department or service is. What you are referring to relates to how well led the trust is as this is discussed in the provider report.

65

25

Urgent and emergency services

 

"There did not seem to be any embedded concern about the management of the risk register including current updates or any regular review".

 

Propose removal: This statement is a subjective opinion that is not evidenced. The Trust includes a range of risk-related documentation by way of evidence that it is concerned about risks and their management. The trust fully accepts that its documentation and systems require improvement, which is why it has invested in web-based incident management system to better support staff with the processes; however, deficits in completing the process elements of risk management do not equate to a failure to identify, a lack of concern about, or action taken in response to, risks.

Not agreed

Having reviewed the risk register we cannot find any identification of perceived gaps or actions to be taken or allocation of tasks. Risk registers and other documentation seen in this respect simply list the issue and a review date which is generally the following year. There is little evidence that staff would know what is happening to the risks raised within their department.

66

25

Urgent and emergency services

 

The delivery of high quality care was not assured by the leadership within the emergency department…. Governance procedures were not being followed in respect of reporting incidents and improving services in response to these.

 

Propose revision: During the period of our inspection, we were not assured that governance procedures that would maximise the opportunity to identify, report and learn from incidents to improve services were followed in the emergency department. The department has a lower than expected rate of incident reporting, at 4% of the trust's overall rate. Staff report that this is reflective of the time it takes to complete reports coupled with lack of feedback from the incidents reported. The Trust had recognised this and invested in web-based incident reporting and risk management software to reduce administrative burden on frontline staff and facilitate improved triangulation and learning from incidents. A Director of Governance and Risk has subsequently been appointed to drive improvement in these areas. Patient outcomes data and the CQC's own national A&E patient survey confirm that the trust is not a negative outlier in respect of harms or patient experience. The Trust's performance in July 2014 fell to 92.9%; its first monthly drop below a 95% achievement. Year to date figure was 95.2%, which compares favourably with other NHS trusts and is not indicative of a poorly managed service.

Agreed

Amended to state: During the period of our inspection, we were not assured that  governance procedures that would maximise the opportunity to identify, report and learn from incidents to improve services were followed in the emergency department. The department has a lower than expected rate of incident reporting, at 4% of the trust's overall rate. Staff reported that this was reflective of the time it takes to complete reports coupled with lack of feedback from the incidents reported. The trust stated that they had recognised this and invested in web-based incident reporting and risk management software to reduce administrative burden on frontline staff and facilitate improved triangulation and learning from incidents. Patient outcomes data and the CQC's own national A&E patient survey confirm that the trust is not a negative outlier in respect of harms or patient experience. The trust's performance in July 2014 fell to 92.9%; its first monthly drop below a 95% achievement. Year to date figure was 95.2%, which compares favourably with other NHS trusts and is not indicative of a poorly managed service.

67

26

Urgent and emergency services

 

"information for all staff about the trusts vision was available in very limited formats"

 

Propose removal: This is not factually correct and the previous paragraph in the draft report states 'the trust was clear about vision and values and produced many leaflets on these', which confirms that the vision was accessible. The Trust's 16-point plan is well known and featured in various formats throughout the trust, with the credo and values of the organisation heavily promoted. On Induction Day 1, staff's first introduction to the trust, presenters fully explore the values and vision for the organisation, including running a team exercise to practice 'Stop the Line' methodology and challenge of others.

Agreed

Amended to state: Information for all staff about the trust’s vision and strategy was available but staff were not aware how to access it.

68

26

Urgent and emergency services

 

"Lack of clinical director had the potential to impact on the culture within the service working with other directorates".

 

Propose removal: As provided to the CQC on two separate occassions, both before and during the inspection, the organisational structure chart evidences that there was in post an executive clinical director lead for the directorate, which hosts the ED and other acute medical departments. The clinical lead is an acute medical consultant with active and highly visible frontline engagement and who evidences significant knowledge and understand on a daily basis of what is happening on the frontline across ED and the other acute medical areas. This is a supposition based on inaccuracy.

Agreed in part

Sentence amended to state: There was an executive director for the emergency department and medical services but staff felt that the lack of an identified senior leader for this service had the potential to impact on the culture within the service working with other directorates in the trust and external stakeholders.

69

26

Urgent and emergency services

 

"We spoke with staff members who told us they do not get department feedback from staff surveys".

 

Propose revision: "We spoke with staff members who told us they do not get department feedback from staff surveys; however the Trust has provided evidence to demonstrate that feedback was communicated in a number of ways, including Around & About Live, Daily Bulletin and display on the Trust's intranet. The Head of Communications also attended divisional team meetings to discuss the results and to provide them with a .pdf copy of their divisions'/team results compared nationally and organisationally."

Not agreed

We cannot accept evidence at the FAC stage unless it fulfils the criteria set out in our policy.

However sentence amended to state: The trust confirmed that feedback was given to staff in a number of ways, however the staff we spoke to told us that they do not get department feedback from staff surveys.

70

26

Urgent and emergency services

 

We observed that there was a disengagement of leadership from the emergency department matron".

 

Propose revision: "In our opinion, we felt that there was disengagement by the emergency department matron, who was leaving the role the following week."

Not agreed

This was evidenced through observation in that the matron was dismissive and did not address the issues highlighted to them and through discussion with six members of staff. Indeed the matron was very rude and dismissive to the A&E inspection team and to the Head of Inspection. This was brought to the attention of senior staff within the trust at feedback.

Medical care [including older people’s care

  • The overall number of medical and nursing staff has increased by 56 full-time posts in the 24 months to September 2014. Our turnover, at 13%, is around average for a trust of our size. Historically, Hinchingbrooke faced problems recruiting consultants, but now we are regularly receiving very high volumes of applications for any advertised posts and we have recruited 30 new consultants in the past 2 years. Our Deanery was previously discussing stopping sending junior doctors to Hinchingbrooke. Both ED and maternity were red-rated. 2 years on, both are green-rated and the Deanery is looking at doubling the number of junior doctors coming to Hinchingbrooke by 2015-16.
  • We have expanded our infection prevention and control team: our last case of MRSA was in February 2013 and while c.difficile remains an area for improvement, we have noticeably fewer cases than in 2012.
  • We have integrated our stroke service with other hospitals, restructured our pathways to bring together medical and surgical gastroenterology to better respond to patients’ needs, and have worked with surrounding trusts to improve training in specialist skills such as respiratory, stroke, dementia and elderly care.
  • Finally, the Clinical Commissioning Group reduced their inspection frequency, from fortnightly to monthly, in recognition of the low risk associated with care on our wards.

 

Thank you for this information which we have considered.

  • In relation to the problems faced by Hinchingbrooke in terms of recruitment the trust does not raise any issues relating to the medical service specifically.

 

  • We have reported that there were no MRSA cases in the current year.

 

  • We have no evidence to support this bullet point and therefore cannot reference it in the report.

 

  • In respect of the reduction in frequency of the CCG visits as we have no corroboration of this we cannot reference this in the report.

 

 

71

27

Medical care (including older people’s care)

 

".. it is meant to provide nursing style home care for patients.."

 

Proposed revision: "It provides care for patients with S5 confirmation of their medical fitness for discharge. Patients admitted to the ward do not necessarily require rehabilitation and are a mix of patients requiring long term residential nursing care provision in the community, as well as those returning to independent living arrangements."

Agreed

Amended to state: It provides care for patients with confirmation of their medical fitness for discharge. Patients admitted to the ward do not necessarily require rehabilitation and are a mix of patients requiring long term residential nursing care provision in the community, as well as those returning to independent living arrangements.

72

27

Medical care (including older people’s care)

 

"Cherry tree ward is a 30 bed ward caring for patients with acute medical conditions". 

 

Proposed revision: "Cherry Tree ward is a 30 bed ward caring for elderly patients with acute medical conditions."

Agreed

Amended to state: Cherry Tree ward is a 30 bed ward caring for elderly patients with acute medical conditions."

73

27

Medical care (including older people’s care)

 

"Medical shortstay unit is a 20 bed ward".

 

Proposed revision: "Medical shortstay unit is a 30 bedded ward".

Agreed

Amended to state: Medical shortstay unit is a 30 bedded ward

74

27

Medical care (including older people’s care)

 

"Prior to this inspection, we were aware through intelligent monitoring that there were higher indicated levels of pressure ulcers and urinary tract infections , we were also aware that the number of patients who had fallen with the fall resulting in injury had increased in recent months."

 

Proposed revision: "Intelligent monitoring had not indicated any increased risk in respect of pressure ulcer, urinary tract infections of falls with harm. The Trust has a low incidence of hospital acquired pressure ulcers and falls with harm." Evidence provided in respect of acquired vs inherited pressure ulcers and falls resulting in injury. >98% of falls reported resulting in no or minimal harm.

Agreed

Amended to state: Monitoring had not indicated any increased risk in respect of pressure ulcer, urinary tract infections of falls with harm. The Trust has a low incidence of hospital acquired pressure ulcers and falls with harm.

75

27

Medical care (including older people’s care)

 

"The re-ablement centre is a 25 bedded mixed sex non acute unit".

 

Proposed revision: "The Reablement centre is a 25-bedded, single-sex compliant, non acute unit."

Agreed

Mixed sex removed.

76

28

Medical care (including older people’s care)

Summary of Findings: paragraph 1

"Medical services were not safe, we found that patients were at high risk from avoidable harm or abuse in Apple tree ward".

 

This is a generalised, disproportionate and unsubstantiated statement. The Trust has HSMR of 78, a Serious Incident rate of 41 in the period incorrectly stated by the CQC to be 102, it is highly placed in the middle group of small acute hospital reporters to NRLS, with a low rate of patient accidents compared with other small acute trusts, a 96.8% rate of no/low harm incidents, indicating a positive reporting culture and low risk of harm. Apple Tree ward has a no/low harm incident rate of 98.1%, which is moderately higher than the trust overall rate. Following investigation of an alleged drag lift, the Trust did not find sufficient evidence to support this allegation based on statements provided by the inspector, the alleged perpetrator, who was a student nurse with a previously exemplary record. Evidence supplied is CQC inspector statement, NRLS report and Apple Tree ward incident data extracted from the incident data provided to the CQC on 19/09/2014.

 

Propose revision: "Medical services in some instances were not safe; we found that patients could be placed at risk in Apple tree ward through a lack of adherence to the National Institute for Health and Care Excellence [NICE] guidelines: CG 179. The Trust has a low rate of hospital acquired pressure ulcer but must maintain compliance with standards to assure that this is maintained or further improved."

Agreed in part

Sentence amended to state Patient's using the medical services were at risk from avoidable harm or abuse in Apple Tree ward. Staff throughout the service were not always adhering to the National Institute for Health and Care Excellence (NICE) Guideline CG:179 ‘Pressure ulcers: prevention and management of pressure ulcers’, because we found little evidence that preventative measures were consistently being implemented. Data on serious incidents has been amended

77

29

Medical care (including older people’s care)

 

"However, during the unannounced inspection, we returned and found that the patient had grade 2 pressure areas on their leg, which had not been assessed or treated."

 

Propose revision: "However, during the unannounced inspection, we returned and found that the patient had leg ulcers, which had not been assessed or treated." Point of clarification: these were not pressure area-related ulcers.

In part

Despite the assertion that these were not pressure area related, the sores can be graded using the pressure sore classification. The sentence amended to However, during the unannounced inspection, we returned and found that the patient had sores which were grade 2 on their leg, which had not been assessed or treated

78

29

Medical care (including older people’s care)

 

"On Apple Tree Ward we observed that 3 people with cannulars had their sites bandaged and therefore the cannula site was not visible."

 

Propose remove: the CQC has offered no evidence that the bandaging of the sites was inappropriate care or led to infection. These patients were prone to pulling out cannula. The Trust questions what level of triangulation was conducted by inspectors, for example in asking staff why this had been done.

Not agreed

Covering cannulae sites is not recommended as signs of extravasation or infection cannot be monitored. There are a variety of ways in which trusts can ensure that patients do not pull cannulae out including the use of mittens once appropriate safeguarding processes have been undertaken.

79

29

Medical care (including older people’s care)

 

"Pressure ulcers prevalence in medical areas has been consistently high in the period between May 2013 and May 2014, with 85 reported pressure ulcers at grade 2, 3 or 4."

 

Proposed revision: "Pressure ulcer prevalence in medical areas has been consistently high in the period between May 2013 and May 2014, with 85 reported pressure ulcers at grade 2, 3 or 4; however, of these, 53 affected patients had been admitted into the trust with the pressure ulcer[s] already present." Point of clarification: the CQC has not differentiated between inherited and acquired pressure ulcers.

Agreed

Sentence amended to include, however the trust states that 53 patients had been admitted to the wards with pressure sores from the community.

80

29

Medical care (including older people’s care)

 

"The medical care service has reported 44 catheter-associated urinary tract infections (UTI’s) between May 2013 and May 2014. This is higher than would be expected for the number of medical beds at
this hospital." Point of clarification: the CQC has not differentiated between inherited and acquired infections.

Not agreed

Data used is that submitted by the hospital and appears in the agreed data pack. It is nationally reported data and used in all NHS trust reports.  However the analyst advises that whilst higher than the England average the significance is not known. Therefore the final sentence altered to state This is higher than the England average.

81

29

Medical care (including older people’s care)

 

"The service had a high incident of patient falls resulting in harm to the patient."

 

Propose remove: There were 9 severe and 10 moderate falls resulting in harm in the 12 months preceding inspection. Evidence was supplied in the document <DR55 TOTAL INCIDENTS APRIL 2013 TO CURRENT> provided to the CQC on 19 September 2014.

Agreed

Following review by the analysts the sentence amended to The service had a lower than England average number of patient falls resulting in harm to the patient.

82

29

Medical care (including older people’s care)

 

"There have been 24 serious incidents (SI’s) reported within the last year. Ten pressure ulcers classified at grade 3 or above, nine falls resulting in harm, two unexpected deaths, and three other accidents whilst in hospital. For the number of beds within the medical care service this is higher than would be expected."

 

Proposed revision: "In the 12 months preceding the submission of the Trust's incident data to the CQC on 19 September 2014, there had been two unexpected deaths and 14 serious incidents reported from the medical  care services, including older people's care. Of the serious incidents, five involved pressure ulcers that had been acquired whilst under the care of the Trust, four involved patient falls, and one was due to serious infection." Evidence of incidents was supplied to the CQC on 19/09/2014 in file <DR55 TOTAL INCIDENTS APRIL 2013 TO CURRENT>

Agreed

Following review by our analysts the data submitted by the trust on 19 September 2014 is more current therefore the sentence changed as In the 12 months preceding the inspection there had been two unexpected deaths and 14 serious incidents reported from the medical  care services, including older people's care. Of the serious incidents, five involved pressure ulcers that had been acquired whilst under the care of the trust, four involved patient falls, and one was due to serious infection.

83

30

Medical care (including older people’s care)

 

"A swab for infection had been undertaken on 16 Sep, but the result had not been received or chased by the team six days later. This patient was at risk of developing an infection in the wound site."

 

Propose revision: "A swab for infection had been undertaken on 16 Sep, but the result had not been received or chased by the team six days later." The latter sentence in respect of risk of infection should be removed as this is not a cause and effect link, though of course the Trust recognises that this delay is poor practice.

In part

Last sentence amended to state This meant that there was a potential delay in treating any infection that may have been present.

84

30

Medical care (including older people’s care)

 

"We found that staff were not classifying the grade, size or type of pressure ulcer, as defined by the ‘European Pressure Ulcer Advisory Panel' (EPUAP). In three sets of notes examined we found entries including ‘sore on toe’, ‘broken area’, ‘red area’, and ‘pressure sore sacrum’. There were no defining factors on the wound type, size,
depth, colour, temperature, or if the area was blanchable or non-blanchable."

 

The Trust wishes to challenge the factual accuracy of this statement and also the extrapolation from three set of notes to 'staff'. There are multiple points of recording within the case records, which is a documentary issue yet to be addressed, but TVNs report that they have only rarely experienced the absence of EPUAP grading and they found it highly improbable that the trust would suddenly experience multiple omissions all coinciding with the inspection. A TVN also visits every patient identified with a pressure area concern and undertakes an independent grading in addition to those already completed by ward staff.

In part

Sentence amended to state

We found that some staff were not classifying the grade, size or type of pressure ulcer, as defined by the ‘European Pressure Ulcer Advisory Panel' (EPUAP). In three sets of notes that we reviewed, we found that staff had not classified the grade, size or type of pressure ulcer….

85

31

Medical care (including older people’s care)

 

"We identified one patient who had been referred for review by the DOLS team…."

 

Propose revision: "We identified one patient who had been referred, to the Adult Safeguarding Lead, for review..." Point of clarification: the Trust does not have a DoLS team.

Agreed

Team reference changed.

86

32

Medical care (including older people’s care)

 

"There was a lead nurse for safeguarding, however when we spoke to the staff only some knew of the safeguarding lead"

 

Propose remove: The Trust asserts that, whilst it is possible that agency staff did not know the details of the safeguarding lead, as her details are posted and visible within every ward, it seems incredible that 'only some' staff would know of her if they were substantive members of any our teams. This statement also contradicts the view expressed in the emergency department, as recorded by the CQC, which is that the safeguarding team were highly visible and effective. Could the CQC provide the number and employment status of those who denied knowledge?

Not agreed

This is what we found on speaking to all grades and employment status of staff. CQC cannot provide the number or employment status of the people spoken to as this would undermine the confidential nature of our inspection and staff would not speak to inspectors if they were to be named. We spoke to ten staff including bank, agency, medical and permanent staff at all levels who did not know who the safeguarding lead was.

87

32

Medical care (including older people’s care)

 

"We identified through examination of 15 sets of medical notes on cherry tree ward, apple tree ward and in the reablment centre there was an under-recognition of delirium".

 

Proposed revision:  "We identified, through examination of 15 sets of medical notes on Cherry Tree ward, Apple Tree ward and in the Reablement Centre,  that there was an under-recognition of delirium, although it is nationally recognised that delirium is a difficult to diagnose condition that is often under-reported." The Trust further challenges the inclusion of this comment as being unnecessarily inflammatory, given the nationally recognised challenges of diagnosis of this condition.

Not agreed

Inspectors checked these sets of notes as patients were displaying obvious signs of delirium. All CQC staff have training in recognition of the signs of delirium We also had a medical doctor and a senior medical nurse on the team both trained in recognition of delirium.

88

32

Medical care (including older people’s care)

 

"during our observations we observed an agency nurse enter a patient's bay whilst they were asleep, the curtain was drawn, and no introductions or consent were given. The staff member then proceeded to wash the patient with little interaction. We heard the patient say 'ouch you're hurting me'....the patient was in bed with noticeable red marks on their arms and leg."

 

Proposed revision: "On Apple Tree Ward, during our observations we observed an agency nurse enter a patient's bay whilst they were asleep. The curtain was drawn and no introductions or consent were heard to be given or received. The staff member then proceeded to wash the patient with little interaction. We heard the patient say 'ouch you are hurting me'. We reported our concerns to the matron in charge to ensure that appropriate action was taken immediately"

Agreed

Amended to state: On Apple Tree Ward, during our observations we observed an agency nurse enter a patient's bay whilst they were asleep. The curtain was drawn and no introductions or consent were heard to be given or received. The staff member then proceeded to wash the patient with little interaction. We heard the patient say 'ouch you are hurting me'. We reported our concerns to the matron in charge to ensure that appropriate action was taken immediately.

89

32

Medical care (including older people’s care)

 

"During the inspection, two members of the inspection team observed two different members of staff move people in an unsafe manner. The manoeuvre used is known as a drag lift."

 

Propose remove: This allegation is disputed and unsubstantiated. An otherwise exemplary student nurse was the subject of this allegation. The student and senior nurse were both suspended whilst this was investigated. The student nurse categorically denied that she took the weight of the patient through the shoulder but admitted placing her hand under the patient's axilla whilst she corrected the patient's sloping posture. She fully acknowledged this was an inappropriate moving and handling technique used whilst she was helping the patient to centralise from a leaning position. The senior nurse had not herself witnessed the event but, on hearing the student's description, stated that she would not consider this to qualify as a drag lift. The statement provided by the CQC did not provide sufficient evidence to validate the allegation. 

Not agreed

Two members of the inspection team witnessed this occurring. One is an experienced inspector and another is a nurse. Both are aware of what constitutes a drag lift. The student nurse said at the time that she had seen this practice used on various wards throughout the hospital. Whilst we may agree that the patient’s body weight was not lifted from the bed this manoeuvre can cause dislocation of shoulders and twists the spine of the person undertaking it. Therefore it remains not safe. We have amended the sentence to state In once instance this manoeuvre whilst not lifting the patient was used to reposition the patient. This can cause shoulder and spinal pain in the patient and carer and is classed as abuse by Age UK.

90

32

Medical care (including older people’s care)

 

"We identified, through examining their records, that they had been given a sedative medicine. There was no best interest assessment or mental capacity assessment referred to in the records, prior or post administration of this medicine, despite the patient lacking the mental capacity to consent to receive this medicine."

 

Propose revision: "We identified, through examining their records, that they had been given a sedative medicine. There was no best interest assessment or mental capacity assessment referred to in the records, prior to, or post, administration of this medicine, despite the patient lacking the mental capacity to consent to receive this medicine. The Trust subsequently commissioned an independent audit of safeguarding that concluded that the medication given was appropriate but documentation of assessments did not refer to either best interest or mental capacity assessment."

Not agreed

The bullet point goes on to state the actions the trust took and its findings.  However sentence added: Following our inspection the trust commissioned an independent audit of this case that concluded that the medication given was appropriate but documentation of assessments did not refer to either best interest or mental capacity assessment.

91

33

Medical care (including older people’s care)

 

"The wards had recently completed THE BEST nursing tool for safe staff levels".

 

Propose revision: "the wards had recently completed the Shelford safer staffing tool." 

Agreed

Amended

92

35

Medical care (including older people’s care)

 

" However length of stay for elective admissions in the general medical serivce are double the england average for length of stay".

 

Propose removal: the Trust does not have elective admissions within its general medical service.

Agreed

Our analyst reports that the trust submitted data as requested for elective admissions however it is unclear as to whether the difference in HHCT’s LOS being 7.9 is significant to the England average of 4.9. Sentence removed.

93

35

Medical care (including older people’s care)

 

"during the inspection we were informed that patients on NIV could be placed in other wards around the hospital and there was an inpatient being NIV treated outside the walnut ward at this time".

 

Propose revision: "Patients may, under clinically appropriate circumstances, receive NIV on other wards, if their primary condition requires treatment under other specialties. In these rare circumstances, ward staff are supported with NIV management by Critical Care Outreach  Practitioners of staff from Walnut."

In part

Addition to bullet point. Other ward staff are supported with NIV management by Critical Care Outreach Practitioners of staff from Walnut. It is unclear if the staff on wards where NIV is undertaken are trained or experienced in looking after patients who are considered level two patients by virtue of the NIV treatment.

94

35

Medical care (including older people’s care)

 

"the ward had requested that this person was not sent back to the ward". Proposed revision: "the ward requested that this person was not sent back to the Trust."

Agreed

Amended

95

35

Medical care (including older people’s care)

 

"the risk of re-admission was much worse for gastroenterolgy at the Huntingdon Treatment Centre with a value of 283."

 

Could the CQC provide details of where this information was sourced, to enable factual accuracy checking, as the Trust does not monitor readmission rates for the Treatment Centre and the statement does not accord with our understanding of the situation.

Agreed

There is an error in the data pack affecting the report.

  • The data pack (slide 13) has the titles “Rheumatology” and “Gastroenterology” transposed. The very high readmission rate is actually for rheumatology and is based on there being 10 readmissions compared to an expected 4. (Given the low numbers, it’s unlikely to be significant.)

The relative risk of readmission for gastroenterology was 119 which is above average but again may not be significant. Sentence removed.

96

35

Medical care (including older people’s care)

 

"the staff on the other medical ward were not as competent as those trained on walnut ward."

 

Propose remove: it is an unsubstantiated generalisation to state that staff on one ward are not as competent as those on another ward. Whilst we recognise that competence in NIV management may not be so advanced in this group of staff, they would be supported by Critical Care Outreach Practitioners or Walnut staff to ensure patients received optimal NIV management.

Agreed

Whilst this is a statement of fact we accept that assistance was provided by other wards. Sentence amended as above.

97

36

Medical care (including older people’s care)

 

"We were informed of an example of a patient who had been an inpatient for over 100 days, despite being medically fit for discharge. "

 

Propose revision: "We were informed of an example of a patient who had been an inpatient for over 100 days, despite being medically fit for discharge; a situation beyond the control of the Trust."

Agreed

Amended to state The trust reported that this was a situation beyond the control of the trust.

98

37

Medical care (including older people’s care)

 

" ...left them feeling undignified. We were concerned that people were being treated in an emotionally abusive manner." The Trust questions how the inspector evidenced a patient's feelings. Similarly, the use of the term 'emotionally abusive' is inflammatory and has not been substantiated. 

 

Proposed revision: "…which we felt lacked dignity. We were concerned that people were not treated in an emotionally supportive manner."

Not agreed

The patient expressed how they felt; it was not a judgement on the part of the inspector. Sentence reads We were concerned that people were not being treated in an emotionally supportive manner.

99

37

Medical care (including older people’s care)

 

"Two staff members informed us they were unware they needed to sit down they had not been told this before."

 

The Trust challenges that it is an absolute requirement to be seated whilst assisting a person to eat. Whilst we fully understand and share the concern that a staff member 'standing over' a patient might not put a person at their ease during their meal, in some circumstances it may be appropriate, either for patient or staff safety. 

Agreed

Sentence removed.

100

37

Medical care (including older people’s care)

 

"We spoke with 23 patients during the inspection, and the majority were complimentary about the care they received from their local hospital but we spoke with, saw and heard extreme examples of where care was inadequate" 

 

Propose revision: "We spoke with 23 patients during the inspection, and the majority <please supply exact number> of patients were complimentary about the care they received from their local hospital but we spoke with, saw and heard extreme examples of where care was inadequate"

Agreed

Number added

101

38

Medical care (including older people’s care)

 

"Overall, whilst the patients we spoke with reported that they felt the care was good on Apple Tree Ward, from the examples provided by the patients, together with our observations of care on the ward, we established that people were not treated with dignity or respect. We were also concerned that people were being treated in an emotionally and institutionally abusive manner." The CQC has not established institutional abuse and this is an inflammatory and unsubstantiated statement. What inspectors witnessed were individual members of staff, including agency nurses, who did not display the values and behaviours expected of them by the Trust. The Trust recognises its responsibility to monitor and address staff actions and behaviours but a failure of management oversight does not equate to institutional abuse. 

 

Propose revision: "Overall, the patients we spoke with reported that they felt the care was good on Apple Tree Ward. Our own observations led us to conclude that patients on this ward were not consistently treated with dignity or respect or in an emotionally supportive and personalised manner."

In part

Sentence re worded to state: Overall, the patients we spoke with reported that they felt the care was good on Apple Tree Ward. Our own observations led us to conclude that patients on this ward were not consistently treated with dignity or respect or in an emotionally supportive and personalised manner. We were so concerned that we made a referral to the local authority’s safeguarding team.

102

39

Medical care (including older people’s care)

 

"A termination of pregnancy service (ToPS) was provided on the Medical Short Stay Unit. The service was provided to women at less than 12 weeks of pregnancy, and covered chemically-induced   terminations only....there was no formalised care plan or care pathway for the undertaking of ToPS on the Medical Short Stay Unit. The pre-planning and arrangements were undertaken through  gynaecology; however, the monitoring and undertaking of the procedure was done by the medical
consultants. "

 

The CQC has incorrectly described the care pathway, which we took pains to explain during inspection when it became apparent that there had been a misunderstanding of the service provided.  Medical miscarriage patients are admitted to the MSSU; the service is known as Medical Termination of Pregnancy [MTOP]. Monitoring of MTOP patients whilst on MSSU is conducted under the care of gynaecology consultants. The Trust can evidence care plans for medical short stay unit for medical miscarriages.

Agreed

Amended to state A medical termination of pregnancy service was provided on the Medical Short Stay Unit. The service was provided to women at less than 12 weeks of pregnancy, and covered chemically-induced terminations only. This service was provided in consultation and joint working with the gynaecology service. However, We did not see any formalised care plan or care pathway for the undertaking of this service on the Medical Short Stay Unit despite the trust stating that there was one. The pre-planning and arrangements were undertaken through gynaecology.

103

39

Medical care (including older people’s care)

 

"If a patient in medical services was placed on a surgical ward, they would be classed as an outlier. However, when a medical patient required a specific service, such as respiratory care, but was placed on the stroke ward, then they were not classed as an outlier. This meant that those patients, who should see a specific consultant for their condition, did not see them outside of the specialist ward area. Consequently, outliers may not be monitored appropriately between medical services."

 

Propose revision: "If a patient in medical services was placed on a surgical ward, they would be classed as an outlier. However, when a medical patient required a specific service, such as respiratory care, but was placed on the stroke ward, then they were not classed as an outlier because they remained within medical services. For these patients, medical review is undertaken at the same frequency as if they were on the specialist ward but the frequency of review by their own consultant might be reduced."

In part

Final sentence amended to state Consequently, the trust reported that the frequency of review by their own consultant might be reduced.

104

39

Medical care (including older people’s care)

 

"these care issues resulted in delayed discharges as planning for discharge only occurred when the patient was medically fit for discharge"

 

Propose revision to provide context: "Whilst planning for discharge commences at an appropriate time within the Trust, delays in discharges occur as the social service element is triggered only once fitness for discharge is confirmed. This is beyond the control of the Trust. "

Not agreed

The trust has a responsibility to work with partners to ensure a timely discharge.

105

40

Medical care (including older people’s care)

 

"a specialist dementia team was employed".

 

Propose remove: HHCT does not employ a specialist dementia team.

Agreed

Sentence amended to state: Despite some staff telling us that there was a specialist dementia team the trust has since confirmed that they do not employ a specialist dementia team.

106

40

Medical care (including older people’s care)

 

"Most patients on Apple Tree Ward and Cherry Tree Ward said that they often did not know who their named nurses were."

 

Propose revision: "Most patients on Apple Tree Ward and Cherry Tree Ward said that they often did not know who their named nurse was, although this information was written above their bed and staff state that they would have introduced themselves."

Not agreed

Whilst the name was written above the bed patients who are bed bound may not be able to see this. However this fact added and sentence states: Most patients on Apple Tree Ward and Cherry Tree Ward said that they often did not know who their named nurse was, although this information was written above their bed. We cannot confirm that staff would introduce themselves as this is not our finding.

107

40

Medical care (including older people’s care)

 

"reablement centre is a mixed sex area  - at time of inspection it was single sex."

 

Propose revision: "The reablement centre is a mixed sex ward with single sex bays. During the inspection, the ward was single-sex; however, this was a time-specific anomaly."

Agreed

Amended to state The Reablement Centre at the time of our inspection was single-sex in each bay, because the ward was being used as an inpatient long-stay medical area, rather than as a rehabilitation service. This was due to capacity within the hospital, and capacity for beds within the community.

108

40

Medical care (including older people’s care)

 

"The Reablement Centre is meant to be a ward that provides support to people to get back into the community. At the time of our inspection, 14 of the 24 patients on the ward were long-term nursing care patients, and were not on the ward to use the rehabilitation services. Therefore, this ward was not enabled to be responsive, due to being used as a general medical ward, rather than as a medical
rehabilitation ward."

 

Propose revision: "The Reablement Centre only accepts patients with S5 confirmation of medical fitness for discharge. Patients admitted to the ward do not necessarily require rehabilitation and are a mix of patients requiring long term residential nursing care provision in the community, as well as those returning to independent living arrangements. This in itself does not prevent the ward from being responsive; however, delayed discharge of care does mean that beds can be taken up by patients who no longer require the services of an acute hospital, thereby preventing others from use of the beds. As noted, there are concentrated issues within the geographical area and beyond the control of the Trust, leading to a significantly increased DTOC rate at Hinchingbrooke compared with national rate. An additional complication is that the DTOC can result in a patient becoming medically unwell again, requiring transfer from the Reablement Centre to other inpatient wards."

Agreed

Sentence Therefore, this ward was not enabled to be responsive, due to being used as a general medical ward, rather than as a medical
rehabilitation ward. Removed and replaced with: This was due to delays in discharge arrangements however the trust reported that this did prevent people who required rehabilitation from using the services provided by this specific rehabilitation ward.

The trust has a responsibility to work with other providers to ensure a timely discharge. This may be an area we can focus on during the quality summit.

109

41

Medical care (including older people’s care)

 

"Locally, nursing staff were positive about the leadership of nursing on Walnut Ward; however, nurses felt that nursing leadership was lacking on Cherry Tree Ward and Apple Tree Ward."

 

Propose revision: "Locally, nursing staff were positive about the leadership of nursing on Walnut Ward; however, nurses felt that nursing leadership was lacking on Cherry Tree Ward and Apple Tree Ward; the Trust confirmed that the Divisional Head of Nursing was on long-term sickness leave."

Agreed

Amended to state Locally, nursing staff were positive about the leadership of nursing on Walnut Ward; however, nurses felt that nursing leadership was lacking on Cherry Tree Ward and Apple Tree Ward; the Trust confirmed that the Divisional Head of Nursing was on long-term sickness leave.

110

43

Surgery

 

'Caring…..Inadequate'.

 

Propose revision: 'Caring….. Requires improvement'. The CQC is referred to the submissions made in this document on the key question of “Are surgical services caring” at Hinchingbrooke Health Care NHS Trust? The trust looks forward to receiving the CQC’s response to the points raised in this document in accordance with the CQC’s factual accuracy procedure. It is the trust’s strong submission that, once the factual inaccuracies have been remedied in the report for surgical services at Hinchingbrooke Health Care NHS Trust, and the wealth of quantative and qualitative data available to the CQC is included, the CQC will be left with residual evidence in this service domain which contains both characteristics of ‘good’ and “requires improvement’ as set out in the Provider Handbook for NHS acute hospitals. The Trust submits that in the light of the factual accuracy submissions made, there are no reasonable grounds to maintain a rating of ‘inadequate’ for ‘caring’ in surgical services at Hinchingbrooke Health Care NHS Trust. Inspectors of this domain appear to have reached their conclusion based predominantly on the limited observations and interviews during of the onsite inspection period without appropriate triangulation and due regard to more detailed relevant data and feedback available to the CQC for the relevant periods or to the inclusion of information for the whole range of surgical services offered to patients. The limited use of the information available to the CQC and the subjectivity demonstrated in this section of the report is not in keeping with CQC methodology and undermines its decision on ratings.

 

The rating of Inadequate for Caring in relation to surgery remains Inadequate. The reasons for this decision are based on the fact that the hospital meets one or more of the criteria for  an inadequate rating namely:

  • Peoples’ basic needs are ignored or not met, including neglect through lack of food, drink or warmth. People feel unsafe, uncomfortable, cold or vulnerable.
  • People do not know who to ask for help, and are not supported to cope with their care and treatment.

This relates to the lack of response to call bells giving rise to a small number of patients reportedly soiling the bed, unsupportive nursing staff not providing emotional support or information for patients.

 

Surgical overall:

As well as the evidence outlined below, our clinical outcomes and patient feedback have been given insufficient weight. These are relevant facts and the trust considers their omission an inaccuracy:

  • In colorectal surgery, elective 90-day mortality after resection, for example, is 1.5%, against NBOCAP average of 2.5%. Overall 90-day mortality is 3.9% against NBOCAP of 4.5%. Elective laparoscopic completed is 85%, against NBOCAP average of 40%.
  • In orthopaedic surgery, the vast majority (42 of 48 metrics) measured by the British Orthopaedic Association, were at or above national average scores. In a report published in September 2014, all surgeons were at or above national PROMs scores.
  • The National Cancer Patient Survey found that 94% of patients rated our care as ‘excellent’ or ‘good’.

 

Thank you for this information which we have considered.

  • We have added in that the mortality in colorectal surgery is better than the England average(2.5%) at 1.5%
  • Unfortunately the data re orthopaedics is outside the inspection timeframe
  • We have reflected the National cancer patient survey throughout the report.

111

44

Surgery

 

"Children were not receiving appropriate care in the operating theatre as there were no dedicated lists or they were not grouped together at the start of a list."

 

Propose remove: This is factually incorrect; paediatric patients are scheduled with consideration for the needs of children and carers and are routinely grouped and scheduled first on the list before adult patients. Wherever possible, paediatric patients are scheduled on dedicated lists but the volume does not routinely fill a full operating session. Evidence is provided in the form of paediatric operating lists between May and August 2014; one case undertaken out of order was due to requirement for X-ray. It would in any case be an unsubstantiated generalisation to state that deviation from a dedicated or grouped list automatically equates to these children not receiving appropriate care. The Trust's surgical outcomes do not indicate any increased risk or incidence of harm. 

Not agreed

Inspectors checked three samples of theatre lists and spoke to the team leader and three other members of staff. The trained paediatric nurse in the operating theatre had not been replaced. Only eight out of 17 staff had had PILS training prior to our inspection. Therefore whilst the outcomes were good there were limited staff with experience of nursing children in the operating theatre.

112

44

Surgery

 

"There were some areas in the care of children, such as delicate airway procedures in operating theatres, that were infrequently carried out, which meant that staff may not have been regularly practiced in the techniques."

 

Propose revision: the terminology of 'delicate airway procedures' is vague. "There were some areas in the care of children being infrequently carried out therefore some staff may not have been regularly practised in techniques; however, outcomes data has identified no area of concern in respect of patient safety."

Agreed

Amended. However the trust may wish to note that this refers to the removal of foreign bodies from airways and not tonsillectomy patients. It was of concern to our specialists that this procedure was undertaken on an occasional basis and therefore skills could be lost.

113

45

Surgery

 

"Five records reviewed in Birch ward had no follow up review of the initial assessment of risk of venous thromboembolism".

 

Propose revision: "Five records reviewed in Birch ward had no follow up review of the initial assessment of risk of venous thromboembolism; however, the trust has dedicated VTE specialist nurses who undertook a clinical audit of VTE practice in June 2014 that identified that thromboprophylaxis met NICE and Trust guidelines in 98.6% of cases, with one patient for whom follow up procedures were not compliant. Root cause analysis had been conducted in 100% of patients with a hospital acquired VTE. Patients with VTE had acquired this in hospital in 28% of instances, against NHS England guidance for commissioners that approximately 50% of all venous thrombosis are in patients who had a hospital admission in the 90 days prior to diagnosis." The CQC has provided no evidence that the five patients had required a follow up review in the time period since the initial review nor is there evidence to suggest that patients are at increased risk of developing VTE under our care.

In part

Amended to state Five records reviewed in Birch ward had no follow up review of the initial assessment of risk of venous thromboembolism when they should have been reviewed.  However data provided by the trust showed that patients were not at an increased risk of developing a venous thromboembolism under their care.

114

45

Surgery

 

"Taps for hand washing and scrubbing up were 'non touch' in main theatres, but this was not the case in the treatment centre theatres."

 

Propose revision: "Taps for hand washing and scrubbing up were 'non touch' in main theatres, but this was not the case in the treatment centre theatres - all taps are WRAS approved and compliant with HTM standards fitted with TMVs. Taps fit in clinical area single wash hand basins are a standard Horne Optitherm but the theatre scrub sinks, where upgraded, have had a Delabie foot operated tap fitted." Current product information is available on their respective web sites.

Agreed

Addition of sentence However the trust reported that these taps were compliant with current guidance.

115

45

Surgery

 

"There were gaps in care planning for pressure ulcer prevention"

 

Propose revision: "There were gaps in care planning for pressure ulcer prevention; however, the Trust has a low rate of pressure ulcers acquired in care and has invested in the purchase of a high rate of pressure relieving equipment, together with the establishment of a medical equipment library to manage the process of provision and to maintain high standards of infection prevention and control in relation to this equipment." Evidence supplied.

Agreed

Amended to state There were gaps in care planning for pressure ulcer prevention. We found that risk assessments for skin integrity had only minimal detail of the care to be put in place to prevent pressure ulcers developing. The trust had sufficient pressure relieving equipment available for staff to use.

116

46

Surgery

 

" only some staff had an interest in paediatric care, and had completed paediatric training courses"

 

Propose remove:  this is factually incorrect. All anaesthetic practitioners and Recovery staff looking after paediatric patients complete paediatric competencies, safeguarding level 2 and life support prior to practising unsupervised with children, as demonstrated in the provided evidence of staff training.

Not agreed

Most of this training occurred following our visit and letter to the trust. Prior to the inspection only half the anaesthetic staff had had training and 8 out of 14 staff in PACU had had training and 8 out of 17 anaesthetic staff had PILs training. Sentence added During our inspection only 16 out of 31 staff had undertaken Paediatric Intermediate Life Support training.

117

46

Surgery

 

"The section of the theatre record showing the time that a patient left the operating theatre was not being completed by theatre or recovery staff. This meant that individual records were not fully complete, and audit of procedures or utilisation of theatres could be inaccurate"

 

Propose revision: "Full details of procedure timings are recorded electronically and used to support audit of procedures and theatre utlisation." The statement in the draft report is factually incorrect. Procedures and operating times are recorded in the theatre register and electronic perioperative patient record (ECaMIS) from which audits are routinely carried out. Evidence is provided  to show that on the day of the CQC inspection this data was being comprehensively recorded, which demonstrates the inaccuracy of this statement.

In part

Sentence amended to state:

The patient’s paper section of the theatre record showing the time that a patient left the operating theatre was not being completed by theatre or recovery staff. This meant that individual records were not fully completed despite it being completed in electronic format.

118

46

Surgery

 

"There were comparatively low rates of attendance at basic life support ranging from 40% - 80% for the surgical teams" - Evidence supplied refutes this; please amend.

Not agreed

The evidence that you have sent p46 Basic Life Support training shows that only 16 people have attended out of the 100+ that are listed in this document.

119

47

Surgery

 

"Since our inspection the trust have told us that the anaesthetists will all have had training in this area by the end of October."

 

Propose revision:  "The CQC were informed that enhanced support for consultants dealing with emergency paediatrics has been put in place and a facility to provide mentored practice with elective paediatric anaesthetics offered." 

Agreed

Whilst this is reflected in the notes of our meetings we are happy to reflect the update reported by the trust.

120

48

Surgery

 

"Patients on surgical wards who had not undergone surgery were not routinely referred for pain management advice."

 

Propose revision: "Patients on surgical wards who had not undergone surgery were not routinely referred for pain management advice but were referred as required."

Agreed

Amended to state: Patients on surgical wards who had not undergone surgery were not routinely referred for pain management advice but the trust reported that these patients were referred as required.

121

48

Surgery

 

"There were no plans in place to resolve the issues other than continued monitoring by the nursing teams."

 

Propose revision: "The CQC was concerned tThe CQC has not provided sufficient clarification of which action plans were reviewed to enable the Trust to check the factual accuracy of this statement.

Not agreed

Sentence clarified to state There were no plans in place to resolve the issues with missed medication although these continued to be monitored by the pharmacy teams. Whilst pharmacy staff highlighted issues in respect of medication we asked for and did not receive any plans to address these. We would have anticipated actions to be taken discussed with staff and recorded, increase in medication reporting on datix system, action plans in place to address this particular issue as a risk had been identified.

122

49

Surgery

 

"The National Audit of patients with bowel cancer in the Trust shows that 28% of patients were seen by a nurse specialist compared to a national average of 88%". 

 

Propose revision: "The National Audit of patients with bowel cancer in the Trust had shown that 28% of patients were seen by a nurse specialist compared to a national average of 88%; however, this data related to a historical period when the specialist covered only part time hours. The specialist nurse role is now full time and 95% of patients know their specialist nurse, which is higher than the more recent national average of 91%." This information was provided to the CQC during interview with Mr David Mitchell but appears to have been overlooked.

Agreed

Amended to state: Data showed that in 2013-14 the length of stay for patients undergoing bowel surgery was worse than the England average. 83% of patients stayed in hospital more than five days compared with the national figure of 69%.

123

49

Surgery

 

In the national hip fracture audit the service had worse than the England average of 96% performance for having a specific falls assessment as 75% of patients with hip fracture were recorded as having the assessment

 

Propose revision: "In the national hip fracture audit the service had worse than the England average of 96% performance for having a specific falls assessment as 75% of patients with hip fracture were recorded as having the assessment. A falls audit, undertaken by the Trust in August 2014, did not specify the patient diagnosis but returned a falls risk identification rate of 91% across seven wards. Areas for improvement, together with planned actions, were included in the audit report.

Agreed

Amended to state: In the national hip fracture audit the service had worse than the England average of 96% performance for having a specific falls assessment as 75% of patients with hip fracture were recorded as having the assessment. A falls audit, undertaken by the trust in August 2014, did not specify the patient diagnosis but returned a falls risk identification rate of 91% across seven wards. Areas for improvement, together with planned actions, were included in the audit report.

124

49

Surgery

 

There is a high proportion of surgeries carried out as emergency procedures (54%) compared to the national average of 18%.

 

Request clarification: The report is unclear about whether the CQC is referring to all surgery or just bowel surgery. An earlier point in respect of prolonged stays after bowel cancer surgery, as patients need longer to recover from emergency interventions than elective.

Agreed

This relates to bowel surgery and the statement has been amended to clarify this.

125

50

Surgery

 

"One patient on a ward told us that they had waited four days for an ultrasound scan. They said they had been to the scan department three times."

 

Propose revision: "One patient on a ward told us that they had waited four days for an ultrasound scan. They said they had been to the scan department three times. Evidence supplied to the CQC during inspection demonstrated a very low level of delayed diagnostic tests, with just eight incidents occurring in the previous 18 months. "

Agreed

Additional sentence added The trust supplied evidence which demonstrated a low level of delayed diagnostic tests, with eight incidents occurring in the previous 18 months.

126

50

Surgery

 

"Staff completed competency checks for new skills, but told us that there was no review of competencies. This could mean that staff lose skills not practised and checked regularly, and may not undertake skills safely."

 

Propose revision: "Staff completed competency checks for new skills, but told us that there was no review of competencies. This could mean that staff lose skills not practised and checked regularly, and may not undertake skills safely; however, staff were issued with a revised competency pack between July and August 2014, which involves completing a separate annual review document." A copy of these documents was provided to the CQC inspectors

Agreed

Amended to state: Staff completed competency checks for new skills, but told us that there was no review of competencies. This could mean that staff lose skills not practised and checked regularly, and may not undertake skills safely: however the trust told us that staff were issued with a revised competency pack between July and August 2014, which involves completing a separate annual review document.

127

50

Surgery

 

...however, new staff in operating theatres were employed under a probationary period, with checks on competencies at 2 monthly intervals for six months."

 

Propose revision: "New staff in operating theatres were employed under a probationary period, with checks on competencies at three-monthly intervals for six months." Use of the word 'However' to link with the previous sentence diminishes the positivity of both practices. The fact that the staff have a six-month probationary period is positive for both parties, as it supports the assessment and optimal placement of people into roles.  Interval quoted is also factually incorrect.

Agreed

Sentence amended to state: New staff in operating theatres were employed under a probationary period, with checks on competencies at three monthly intervals for six months.

128

50

Surgery

 

The surgical service was rated as inadequate, as patients basic needs were not being met. Many patients in different wards told us that they had to wait unacceptably long periods when they called for assistance. This resulted patients not receiving care that protect their dignity. Some of these delays resulted in patients soiling themselves. Some patients told us that there was little time for nurses to provide emotional support and explanations about care to patients and relatives. However some patients also told us that they had had experiences of nurses being kind and considerate in providing care.

 

Propose revision: 'The surgical service was rated as requires improvement, as, although many areas of surgical care provision were meeting or exceeding required standards, patients’ basic needs were not being met in all cases. <Please supply exact number of surgical patients telling inspectors that they waited unacceptably long periods for assistance> out of <please supply exact number of surgical inpatients at the time of inspection> surgical inpatients told us that they had to wait unacceptably long periods when they called for assistance. This resulted in some patients not receiving care at the expected level required to protect their dignity. Some <please supply exact number> of these delays resulted in patients soiling themselves. Some < please supply exact number> patients told us that there was little time for nurses to provide emotional support and explanations about care to patients and relatives, although it is recognised that this is not a role limited to nursing staff. Some <please supply exact number> patients also told us that they had had experiences of nurses being kind and considerate in providing care. It is the trust’s strong submission that, once the factual inaccuracies have been remedied in the report for surgical services at Hinchingbrooke Health Care NHS Trust, and the wealth of quantative and qualitative data available to the CQC is included, the CQC will be left with residual evidence in both of these domains which contains both characteristics of ‘good’ and “requires improvement’ as set out in the Provider Handbook for NHS acute hospitals. The Trust submits that in the light of the factual accuracy submissions made, there are no reasonable grounds to maintain a rating of ‘inadequate’ for the ‘caring’ domain in surgical services  at Hinchingbrooke Health Care NHS Trust.  Inspectors of this domain appear to have reached their conclusion based predominantly on the limited observations and interviews during of the onsite inspection period without appropriate triangulation and due regard to more detailed relevant data and feedback available to the CQC for the relevant periods. The limited use of the information available to the CQC and the subjectivity demonstrated in this section of the report is not in keeping with CQC methodology and undermines its decision on ratings. Further, the report has not demonstrated that patient feedback received from mixed speciality wards has been assigned uniquely to the service under which the patient was admitted.

In part

Sentence amended to state: 'The surgical service was rated in this domain as inadequate as, although many areas of surgical care provision were meeting or exceeding required standards, patients’ basic needs were not being met in all cases. 17 out of 30 surgical inpatients told us that they had to wait unacceptably long periods when they called for assistance. This resulted in some patients not receiving care at the expected level required to protect their dignity. Two patients told us that they had been told to soil themselves and a further one patient stated that delays resulted in patients soiling themselves. Five patients told us that there was little time for nurses to provide emotional support and explanations about care to patients and relatives, although it is recognised that this is not a role limited to nursing staff. Fifteen patients also told us that they had had experiences of nurses being kind and considerate in providing care.’

129

51

Surgery

 

"Many patients across all surgical wards told us that they had to wait half an hour or longer when they were bed-bound but required a nurse to use the toilet."

 

Propose revision: "Many patients across all surgical wards told us that they had to wait half an hour or longer when they were bed-bound but required a nurse to use the toilet. Evidence provided to the CQC of a call bell audit undertaken by the Trust on Juniper ward in the week prior to our visit  indicated that waiting times ranged from 2 to 8 minutes, with an overall average of 4 minutes from call to response. The concerns raised with us by patients may have been a recently emerging risk."

Agreed

Sentence amended to state Many patients across all surgical wards told us that they had to wait half an hour or longer when they were bed-bound but required a nurse to use the toilet. The trust provided evidence of a call bell audit undertaken by the trust on Juniper ward in the week prior to our visit that indicated that waiting times ranged from 2 to 8 minutes, with an overall average of 4 minutes from call to response. The concerns raised with us by patients may have been a recently emerging risk however this could not be confirmed.

130

51

Surgery

 

"One patient on the orthopaedic ward (Juniper) said that they had been on seven wards in the first three days of admission, and had been moved at 12.45am, 3am and 5am on different days.

 

Propose revision: "One patient on the orthopaedic ward (Juniper) said that they had been on seven wards in the first three days of admission, and had been moved at 12.45am, 3am and 5am on different days. The Trust has confirmed this but note that these moves include spells in the assessment unit and intensive care unit. The most recent national inpatient survey in 2013 shows that 98% of the Trust's patients had stayed on three or fewer wards, with the majority [62%] accommodated in one ward only."

Not agreed

The real issue here is the times of the moves not the fact that they occurred despite this not being best practice. These were all overnight moves and should be avoided.

131

51

Surgery

 

"The Orthopaedic ward (Juniper)".

 

Propose revision: The Acute Surgical and Trauma Ward [ATSU]. Factual inaccuracy.

Agreed

Amended

132

51

Surgery

 

"There were quiet sliding doors across bays which helped to maintain a quiet environment for rest in bays. Patients said this meant the nurses could not easily hear patients calling out for help when the call bell was not used."

 

Propose revision: "There were quiet sliding doors across bays which helped to maintain a quiet environment for rest in bays. Patients said this meant the nurses could not easily hear patients calling out for help when the call bell was not used; however, this was not substantiated via nursing staff."

Agreed

Amended to state: There were quiet sliding doors across bays which helped to maintain a quiet environment for rest in bays. Patients said this meant the nurses could not easily hear patients calling out for help when the call bell was not used; however, this was not substantiated via nursing staff.

133

51

Surgery

 

"Two patients in Daisy Ward told us that in Juniper ward the nurses had very little time to provide emotional support."

 

Propose revision: "Two patients in Daisy Ward told us that in Juniper ward the nurses had very little time to provide emotional support; however, it is a trust expectation that such support is provided by the whole of the multi-disciplinary team and is not a role restricted to nursing staff."

Not agreed

This is the patients’ perception of their patient experience and not a judgement from CQC

134

53

Surgery

 

"However, we found that patients in all area discussed problems with us, such as poor response to call bells, and lack of time to talk to patients."

 

Proposed revision: "However, we found that patients in all area discussed problems with us, such as poor response to call bells, and lack of time to talk to patients. Evidence provided to the CQC of a call bell audit undertaken by the Trust on Juniper ward in the week prior to our visit  indicated that waiting times ranged from 2 to 8 minutes, with an overall average of 4 minutes from call to response."

Not agreed

The call bell audit only relates to Juniper and not all areas which is what is being referred to here in terms of reporting upon direct patient experience as reported to us.

136

54

Surgery

Culture within the service

"Nursing staff told us they felt supported by their managers.  They said they felt able to speak openly if they had a concern. There were clear problems raised by patients with inspectors, but it was not evident that staff were empowered to raise concerns regarding the level of care they were able to provide."

 

Propose revision: "Nursing staff told us they felt supported by their managers.  They said they felt able to speak openly if they had a concern'.  Lack of evidence does not equal evidence; it is therefore misleading to make the supposition about empowerment.

Agreed

Sentence amended to

Nursing staff told us they felt supported by their managers.  They said they felt able to speak openly if they had a concern. There were clear problems raised by patients with inspectors, but there were no incidents reported that staff had raised concerns regarding the level of care they were able to provide.

137

54

Surgery

 

"Although there was clear evidence that patients were unhappy with the service, it was not clear how staff of the ward or trust managers intended to tackle the issues on Juniper Ward of missed medication, poor emotional support and lack of continuity of care. This meant that managers had not responded to negative patient feedback and information that indicated the problems that could be leading to patient dissatisfaction."

 

Propose remove: evidence provided

Agreed in part

Sentence amended to state Although there was clear evidence that patients were unhappy with the service on Juniper ward, it was not clear how staff of the ward or trust managers intended to tackle the issues of missed medication, poor emotional support and lack of continuity of care. This meant that managers had not responded to recent negative patient feedback and information that indicated the problems that could be leading to patient dissatisfaction at the time of our inspection.

138

54

Surgery

 

Feedback showed that in March, May and June they were significantly less likely to recommend service. Propose removal:  this comment is removed as have extensive family and friends feedback to corroborate that they would recommend.

Not agreed

This comment relates to Juniper ward and the sentence has been amended to clarify for the reader.

139

56

Critical Care

Safe:  Bullet point 1 under safety thermometer section

"May 2014 to May 2014".

Agreed

Amended to May 2013 to May 2014

140

56

Critical Care

Safe:  Bullet point 2 under safety thermometer section

"small number of catheter infections" .

 

Proposed revision: "There were no catheter infections acquired within critical care but two patients admitted with urosepsis."

Agreed

Sentence amended Safety Thermometer data showed there had been two catheter infections reported between March 2014 and May 2014. These were patients that had been admitted to the unit with infections.

141

56

Critical Care

Safe:  Bullet point 3 under safety thermometer section

"There were insignificant numbers of MRSA or CDiff infections recorded in the critical care centre."

 

Proposed revision: "There were zero incidences of hospital acquired MRSA or C. diff in critical care in 2013/14 and in 2014 to current date"

Agreed

Amended

142

56

Critical Care

Safe:  Paragraph 1

"..meant that cardiology staff were needed to support at times to maintain safe medical cover.” 

 

Propose revision: " ..meant that cardiology staff carry out routine daily cardiology rounds and manage their patients"

Not agreed

Cardiology staff were frequently seen supporting colleagues in the critical care area with routine investigations and monitoring.

143

57

Critical Care

Safe:  Bullet point  1 under nursing staffing

"The expected number of staff per shift was six on the day shift, and five registered nurses at night."

 

Proposed revision: "The expected number of staff per shift is six registered nurses and one HCA on a day shift and five registered nurses and one HCA on a night shift"                                                                     .

Agreed

Amended to state: The expected number of staff per shift is six registered nurses and one healthcare assistant on a day shift and five registered nurses and one healthcare assistant on a night shift.

144

57

Critical Care

Safe:  Bullet point  1 under nursing staffing

There were five level 3 beds, and nominally four level 1 and level 2 beds. Three of these four beds were though used for coronary care patients and so the estimate of nurses required was not as for a straightforward intensive care unit."

 

Proposed revision: "There are five level 3 beds and four level 2/1 beds.  These beds are used flexibly depending on patient need.  Three of these beds are nominally coronary care beds."      

Agreed

Amended to state: There are five level 3 beds and four level 2/1 beds.  These beds are used flexibly depending on patient need.  Three of these beds are nominally coronary care beds.

145

58

Critical Care

Safe:  Bullet point  1 under medical staffing

"Medical cover was 24 hours a day, seven days a week." 

 

Proposed revision: "Consultant Anaesthetist cover is 24 hours per day, seven days per week."                                      

Agreed

Amended

146

59

Critical Care

Effectiveness:  Bullet point 4 under multi-disciplinary working

"The trust resuscitation officer was based in the Critical Care Centre."

 

Proposed revision: "The Trust's Resuscitation Officer was based in the Critical Care Division."                                         

Agreed

Amended

147

60

Critical Care

Responsiveness:  Bullet point 3 under access and flow

"There was only one side room".

 

Proposed revision: "There are three side rooms available."                                                                       

Agreed

Amended

148

61

Critical Care

Well Led:  Bullet point 1 under vision and strategy

"There were no clear plans for how many beds, of either coronary care or critical care," 

 

Proposed revision: "There are clear plans for beds in the new unit.  Nine beds are to be used flexibly, as now, plus a tenth bed area to allow for future proofing."                                                     

In part

Sentence amended to state Staff we spoke with were unaware of the plans for the unit. The trust stated that were plans for ten beds in the new unit.

149

62

Critical Care

Well Led:  Bullet point 2 under innovation, improvement and sustainability

"...there would also be some coronary care beds allocated within other ward areas."

 

Proposed revision: "There will be some monitored beds allocated within other ward areas."                        

Agreed

Amended to state: Medical staff told us that it was their intention that in the development of the new critical care unit in early 2015 there would also be some mointored beds allocated within other ward areas.

150

63

Maternity

Information about the service: paragraph 1

"The hospital managed 3,218 hospital births and 96 home births since April 2013."

 

Propose revision: "The hospital managed 3105 hospital births and 92 homebirths since April 2013."

Not Agreed

The figures (3,218 and 96) were provided by the trust in a document called DR11 Births Data and are based on April 2013 – August 2014 inclusive.

151

63

Maternity

Ratings page - overall commentary

The provider respectfully notes its disappointment that the inspectors have omitted to include a range of innovations that were evidenced to the inspectors during their visit and which we believe takes this service from a 'good' rating to one of 'outstanding'. 1) No mention that complementary therapies is used to help reduce the number of medical induction of labour, a new and innovative care pathway that has been adopted into the community, has been published and utilised to support several other units in the UK, ensuring the spread of innovation.  The indication of complementary therapy pathway has won an innovation award, and the finance from this award has been utilised to train other midwives in complementary therapy methodology and allowed the service to be moved to the community setting near to women's homes. This is unique in the NHS. 2) The maternity unit has funded, using innovative methodology, a part time research midwife who is active in local, national and international research. This is unusual in a unit of this size. 3) The maternity unit supports high levels of staff education, including formal courses at university and online leadership courses. It utilises "one-up methodology" to encourage succession planning and enhance staff training. 4) Three clinics a week are undertaken by midwives trained in the examination of the new-born, freeing up paediatric staff. This innovative clinic system supports an early discharge process. 5) the maternity unit had received an award entitled "mum's award" which was awarded following the nomination of the team by a woman who received care in the maternity unit in 2012. 6) Urogynaecology team was successful in achieving peer review accreditation at a time when they were the smallest gynaecology team to achieve this level accreditation in the country.

 

In response to each of the numbered matters raised::

  • Complementary therapies are frequently offered in maternity services across the country. However this has been added under responsiveness.
  • A research midwife added to report.
  • We are unable to corroborate what is stated as high levels of education and therefore cannot use this evidence.
  • Whilst there may be a midwife led clinic for new borns we have not seen the evidence of this and therefore cannot use this evidence.
  • We do not usually comment on the Mum’s award
  • We are unsure as to when this occurred and therefore cannot use this evidence.

152

63

Maternity

Summary of Findings: paragraph 2

"Staff in the hospital and community were flexible in working practices and responding to the needs of women and babies, although there was currently a strong reliance on goodwill to achieve this at times."

 

Propose remove: The staff in the hospital underwent a consultation circa 5 years ago, which agreed on a call system for hospital midwives; community midwives, as part of the agreed escalation planned for the department, rotate into the hospital to support acute service delivery as required. All work is subject to weekly scale payment and as such, is financially recompensed.

Agreed

Sentence amended to state: Staff in the hospital and community were flexible in working practices and responding to the needs of women and babies

153

64

Maternity

Safe: Bullet point 1 under Cleanliness, infection control and hygiene section

"We found no concerns during the inspection of the maternity units."

 

Propose revision: "We found no concerns during the inspection of the maternity unit." Factual accuracy; only a single unit.

Agreed

Amended

154

65

Maternity

Safe: Bullet point 1 under Environment and Equipment section

"We raised with the provider concerns regarding the distance of the resuscitation trollies to some key clinical areas. The provider agreed to review the siting of the trollies although no concerns had been raised previously."

 

Propose remove: Time tests were previously completed three years ago for siting of the resuscitation trolley. The trollies are available to all parts of the maternity wards within 3 minutes, which the Trust's Resuscitation Team agreed does not pose a risk to patient safety/ outcomes.

Agreed

Amended to state : We raised with the provider concerns regarding the distance of the resuscitation trolleys to some key clinical areas. The trust confirmed that it had undertaken time tests and that all trolleys were accessible within three minutes.

155

65

Maternity

Safe: Bullet point 1 under Midwifery staffing section

"midwife to birth ratio is 1 to 25"

 

Propose revision: "Midwife to birth ratio is 1 to 28 births; when management and specialist midwives are included this rate improves further to 1 to 25 births."

Agreed

Amended to state: Midwife to birth ratio is 1 to 28 births; when management and specialist midwives are included this rate improves further to 1 to 25 births

156

65

Maternity

Safe: Bullet point 2 under Medicines section

"We noted that some intravenous fluids were stored in unlocked cupboards, and we reported this to the Trust at the time"

 

Propose revision: " At the time of inspection, we noted that some intravenous fluids were stored in unlocked cupboards for rapid access in an emergency situation. The Trust had already ordered, and was awaiting delivery of, quick release time locks, which have subsequently been fitted and are now in use."

In part

Sentence amended to state We saw that locked drugs cabinets were in place for controlled drugs, we noted that some intravenous fluids were stored in unlocked cupboards, and we reported this to the trust at the time. The trust reported that they were awaiting delivery of digital locks and have replaced all locks with digital lock to ensure security of these areas. The trust states that these are now in place.

157

65

Maternity

Safe: Bullet point 3 under Consent, MCA, DOLS section

"It was reported that there was a vulnerable women's lead midwife who worked closely with the mental health teams to pick up capacity issues"

 

Propose revision:  "It was reported that there was a vulnerable women's lead midwife who worked closely with the mental health teams to pick up mental capacity issues"

Agreed

Amended to state: It was reported that there was a vulnerable women's lead midwife who worked closely with the mental health teams to pick up mental capacity issues

159

66

Maternity

Effective:  Bullet point 3 under Evidenced Based Care and treatment section

"We spoke with one doctor who had recently secured an appointment as speciality group lead with reproductive health and childbirth"

 

Propose revision: "We spoke with one doctor who had recently become the Strategic Clinical Network Lead for high risk obstetric care."

Agreed

Amended to state: We spoke with one doctor who had recently become the Strategic Clinical Network Lead for high risk obstetric care within the Eastern Clinical Research Network (CRN: Eastern), and will lead the development of CRN: Eastern clinical activity within this specialty; to encourage local clinicians across the region to participate in clinical research network portfolio studies, build upon local clinical strengths, and research interests and priorities, which was noted as good practice. 

160

66

Maternity

Safe: Bullet point 2 under Midwifery staffing section

"Ratio of supervisor midwifes is 1 to 15 which is satisfactory" 

 

Propose revision: "Ratio of supervisor midwifes is 1 to 15 which meets the national standard"

Agreed

Amended

161

67

Maternity

Effective:  Bullet point 1 under Multidisciplinary working section

"The event achieved the objectives set, which were to engage effectively with a wide range of stakeholders ,and to identify the shape and framework of future pathways of care. It was reported that after government reviews of Cambridgeshire area, the provider may be eligible for funding from the government to link up ways with working in maternity and paediatrics in the future"

 

Propose revision: "The event achieved the objectives set, which were to engage effectively with a wide range of stakeholders and to put in place a review process across three regional maternity units to shape future pathways of care."

Agreed

Amended to state: The event achieved the objectives set, which were to engage effectively with a wide range of stakeholders and to put in place a review process across three regional maternity units to shape future pathways of care.

162

67

Maternity

Effective:  Bullet point 2 under Patient Outcomes section

"The trust had a lower than England average of caesarean section births at 7% as opposed to 10%"

 

Propose revision: "The Trust's elective caesarean section birth rate is 7%, which is significantly lower, and thus better, than the England average rate of 10%."

Agreed

Amended to state: The trust had a better than the England average number of caesarean section births at 7%. The national average is 10%.

163

67

Maternity

Effective:  Bullet point 5 under Patient Outcomes section

"Breastfeeding initiation rates were 82%, although this dropped below national levels to 54% in August 2014 at discharge. Additional initiatives were being encouraged to improve this."

 

Propose revision: "Breastfeeding initiation rates were 82% against a target of 80%, dropping at discharge to 64.6% in 2014 [including mothers supplementing their breastfeeding, for example with formula milk]. This percentage drop in August 2014 is accounted for by just three women. The Trust has achieved Level 1 Unicef's Baby Friendly Initiative Certificate of Commitment and is actively working towards Level 2."

Not agreed

These were the rates the trust reported to CQC. Our analysis has reviewed this information and suggests that the figure of 64% is not within the dates given in this bullet. We round percentages up or down so 54.5% has been rounded up to 55%

164

68

Maternity

Caring:  Bullet point 1 under Compassionate care section

"The majority of patients told us that staff responded compassionately to discomfort and emotional distress in a timely and appropriate way. However, we did receive a significant complaint regarding breast feeding support and staff attitude during the inspection which had been highlighted previously in the maternity survey."

 

Propose revision: "The majority of patients told us that staff responded compassionately to discomfort and emotional distress in a timely and appropriate way. However, we did receive a significant complaint regarding breast feeding support and staff attitude during the inspection, in line with dissatisfaction highlighted previously in the maternity survey. The Trust is working actively towards achievement of Level 2 Unicef's Baby Friendly Initiative and recent audits undertaken to support that process have demonstrated good breast feeding support and staff attitudes. "

Agreed

Sentence added: The trust is working towards achievement of Level 2 Unicef's Baby Friendly Initiative and recent audits undertaken to support that process have demonstrated good breast feeding support and staff attitudes.

165

69

Maternity

Responsive:  Bullet point 3 under Service Planning and delivery section

"there were service level agreements in place to support the service, but further development was required, as parts of the current practice relay on goodwill as opposed to formal undertaking".

 

Propose revision: "there were service level agreements in place to support the service, but further development was required. The SLA is to be reviewed as working practices have altered since its last review two years ago." The CQC has not provided evidence for factual accuracy checking that support the assertion of reliance on goodwill.

Agreed in part

Sentence amended to state:  The trust told us that the service level agreement with the trust providing paediatric cover is to be reviewed as working practices have altered since its last review two years ago. In discussions with senior managers at the trust we were told that the day to day practice of the SLA did not follow the terms agreed in the SLA (i.e. 30sessions per annum) but relied on historic working practices.

166

69

Maternity

Responsive:  Bullet point 4 under Service Planning and delivery section

"The unit was currently planning to go for the level 2 baby-friendly award, which would require developments in breastfeeding retention numbers."

 

Propose revision: "The unit is currently working towards Unicef's Baby Friendly Initiative award at level 2, which requires demonstration that all staff are educated to the same standard and continually audit services to promote and sustain breastfeeding."

Agreed

Amended to state The unit is currently working towards Unicef's Baby Friendly Initiative award at level 2, which requires demonstration that all staff are educated to the same standard and continually audit services to promote and sustain breastfeeding.

167

69

Maternity

Responsive:  Bullet point 5 under Meeing People's Individual Needs section

"A birth after thoughts service is offered to support women post natal."

 

Propose revision: "A birth afterthought service is offered to support women and families post fetal loss, during pre pregnancy planning and the ante natal period and post birth. Vaginal birth after caesarean section (VBACS) clinics were available to support women in their care pathway."

Agreed

Amended to state: A birth afterthought service is offered to support women and families post fetal loss, during pre pregnancy planning and the ante natal period and post birth.Vaginal birth after caesarean section (VBACS) clinics were available to support women in their care pathway

168

69

Maternity

Responsive:  Bullet point 5 under Meeing People's Individual Needs section

"A complementary therapy service had been introduced to reduce anxiety in women post-date, and vaginal birth after caesarean section (VBACS) clinics were available to support women in their care pathway."

 

Propose revision: "A complementary therapy service had been introduced  to induce the labour of women whose pregnancy has post dates in order to avoid medical induction of labour. This new and innovative pathway has been adopted into the community as well as being published and adopted by other units in the UK."

Agreed

Amended to state A complementary therapy service had been introduced to induce the labour of women whose pregnancy has post dates in order to avoid medical induction of labour. This service is available in many hospitals throughout England and is not now seen as innovative.

169

70

Maternity

Well-Led:  Bullet point 1 under Culture with the service section

"culture was openly transparent, staff were clear where they were performing well, but also where other areas of improvement such as breast feeding rates"

 

Propose revision: "..culture was openly transparent, staff were clear where they were performing well and also had clear aspirations for further improvement in areas such as breast feeding rates"

Not agreed

The proposed rewording of the sentence not a factual inaccuracy CQC did not independently collect evidence that staff had aspirations for further improvement. Staff were aware of the need for improvement but did not express aspirations.

170

70

Maternity

Well-Led:  Bullet point 2 under Public and Staff Engagement section

"The response rate to the FFT was low; results obtained showed that 75-84% of women were extremely likely to recommend the survey as of July 2014"

 

Propose revision: "The response rate to the FFT was low; however, the feedback results obtained showed that 75-84% of women were extremely likely to recommend the service as of July 2014"

Not agreed

There is no factual inaccuracy.

171

71

Maternity

Well-Led:  Bullet point 2 under Innovation, Improvement and Sustanability section

"There had been a drop in delivery rates in the last year, and the commissioners were reviewing funding accordingly".

 

Propose revision: "There had been a drop in delivery rates in the last year, and the commissioners are undertaking a 5 year planning review of the provision of maternity services across the 3 maternity units in their commissioning area."

Agreed

Amended to state: There had been a drop in delivery rates in the last year, and the commissioners are undertaking a 5 year planning review of the provision of maternity services across the three maternity units in their commissioning area.

173

MULTIPLE LINES

End of Life Care

 

National Audit of Care of the Dying 2012/13' Please use the more recently published National Audit of Care of the Dying [May 2014] report: This shows the the Trust is at least on a par with most participating trust. It also reports that 'most participating trusts reported operating a 9–5, 5-day face-to-face SPC service (73%, n=96) and the vast majority of trusts reported the availability of an out-of-office-hours telephone service (91%, n=119)'. The trust's provision was exactly in line with that but had not yet achieved the recommendation to extend face to face specialist palliative care services across weekends. The trust has been criticised in the reports for such performance, yet this is on par with the majority of NHS participating trusts.

Agreed

NCDAH was carried out through a case note review for patients who died in May 2013 and the collection of organisational data, submitted to the audit October/November 2013. Some of this data was for the 2012/13 financial year. The results were published May 2014.

In the data pack, the data is described as the National Care of the Dying Audit - Hospitals (NCDAH) 2012/13 but it is the same data that underlies the May 2014 report. We have amended the report to refer to the audit in a consistent way. We have also reflected where the trust is on par with other NHS hospitals.

174

MULTIPLE LINES

End of Life Care

 

The CQC makes reference to both the 2012/13 and 2014 National Care of the Dying Audits. 

 

Please ensure use of most recent audit data.

 

As above

175

83

End of Life Care

Safe: Bullet point 1 under Mandatory Training section

"The results showed the trust scored 0 against the England average which was 7 for care of the dying, continuing education, training and audit"

 

Propose revision: "Within the National Audit of Care of the Dying [May 2014], the results showed that, for organisational indicators, the Trust had fully achieved 3/7 domains, which was equal to the average achievement rate of all participating trusts. It had scored 0/7 for the domain of 'continuing education, training and audit'. The Trust had, in the week of our inspection, implemented a training programme to address this deficit. For clinical performance indicators, the trust had performance better than the average score in 6/8 domains."   KPI evidence provided

Agreed

Sentence amended to state: The National Care of the Dying Audit (May 2014) scored trusts out of 20 for the continuing education, training and audit of staff in care of the dying. Eighteen per cent of participating organisations, including this trust, scored zero compared to an England average of seven. The trust has told us that it had, in the week of our inspection, implemented a training programme to address this deficit.

176

83

End of Life Care

Safe: Bullet point 4 under Mandatory Training section

"The specialist palliative care team told us that they would like to provide more training but they also realised this was difficult due to under-resourcing within the team."   

 

Propose revision: "The specialist palliative care team recognised that having three specialist palliative care nurses covering two whole equivalents meant that prioritisation of patient need impacted on educational delivery."

Not Agreed

This is not factual inaccurate the trust proposes rewording of the sentence.

177

84

End of Life Care

Safe: Bullet point 1 under Mandatory Training section

"None of the staff at ward level, or in the bereavement office and mortuary, had received advanced communications training to enable them to have difficult conversations with patients or representatives." 

 

Propose revision: "Specialist palliative care nurses have attended  the Advanced Communications Course and have, alongside all Cancer Specialist Nurses and Consultants in the field of cancer,  been trained to Level 2 in psychological assessment. There is only one local provider of advanced communications training. It is not an expectation that ward staff would routinely receive this training but may require additional relevant training to better support patients, relatives and representatives." Evidence provided.

Not agreed

Whilst we do not expect all ward staff to have training it is good practice for those wards where dying patients are a frequent occurrence have some training in this area as should those who come into contact with bereaved relatives. However in order to provide a balanced report we have included Specialist palliative care nurses have attended  the Advanced Communications Course and have, alongside all Cancer Specialist Nurses and Consultants in the field of cancer,  been trained to Level 2 in psychological assessment.

178

85

End of Life Care

Effective: Bullet point 3 under Pain Relief section

"The specialist palliative care nurses were being supported to become nurse prescribers." 

 

Propose revision: "The specialist palliative care nurses have been supported to become nurse prescribers and two of the three have already qualified." 

Not agreed

No evidence presented to suggest this was in place at the time of our visit. We asked PCN’s and they stated that they did not have this training.

179

85

End of Life Care

Effective: Bullet point 3 under Pain Relief section

Please replace "Theresults" with "The results"

Agreed

Amended

180

88

End of Life Care

Responsive: Bullet point 7 under Meeting people's individual needs section

"Although these patients were fast tracked for continued health care funding, it could take a long time to arrange packages of care. This meant that patients may not have always been discharged to their preferred place of care in a timely manner."

 

Propose revision: "Although these patients were fast tracked for continued health care funding, it could take a long time to arrange packages of care. This meant that patients may not have always been discharged to their preferred place of care in a timely manner. This element of care was beyond the control of the Trust as it relied on the decisions and actions of another agency."

Not agreed

The trust should work collaboratively with partners as per Regulation 24 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

181

93

Outpatients and diagnostic imaging

Safe: Bullet point 1 under Mandatory Training section

This paragraph contain a number of typographical errors. Please amend these accordingly.

 

Apologies The programme that generates the report does not as yet have a spell check facility. The two typographical errors have been changed. 

182

93

Outpatients and diagnostic imaging

Safe: Bullet point 2 under Mandatory Training section

Please amend "The trust told us that they we aware" to "The trust told us that they were aware"

Agreed

Amended

183

94

Outpatients and diagnostic imaging

Effective: last paragraph under Patient Outcomes section

"[CF1] I have checked this with Butch and it appears that the new to follow up ratios were consistently below the England average except in November /Dec13 - this contradicts what was presented in the data pack which states that both Hinchingbrooke and Huntingdon have much better new to follow-up ratios." The Trust requests that this drafting note is removed and that an accurate description of the Trust's performance is provided.

Agreed

Amended Apologies

184

95

Outpatients and diagnostic imaging

Caring: Bullet point 4 under Compassionate Care section

"Within the radiology department we saw that changing facilities were not separate for males and females; however, there were separate cubicles with curtains screened across to help to preserve privacy and dignity."

 

Propose revision: "There are separate male and female changing facilities in the MRI/CT department." Factual inaccuracy in this section of report only; it is noted correctly elsewhere in the draft report

Agreed

Amended to state: Within the radiology department we saw that changing facilities were separate for males and females. There were separate cubicles with curtains screened across to help to preserve privacy and dignity.

185

99

Outstanding practice and areas for improvement

Areas for improvement (Must Do): Bullet point 6

The area for improvement described in the report related specifically to children and not patients of "all ages". Similarly, the areas of concern were related to the emergency department and operating theatres. The Trust requests that this statement is amended to read as" Ensure an adequate skill mix in the emergency department and operating theatres, to ensure that children receive a service that meets their needs".

Not agreed

Bullet amended as per CIoH letter:

Ensure an adequate skill mix in the emergency department and theatres  to ensure that paediatric patients receive a service that meets their needs in a timely manner.

Ensure that there are sufficient appropriately skilled nursing staff on medical and surgical wards to meet patients’ needs in a timely manner.

186

99

Outstanding practice and areas for improvement

Areas for improvement (Must Do): Bullet point 8

"Improve infection control measures across the whole service, to protect patients from infection through cross contamination." 

 

The report identified that several core services were compliant with infection control measures and the Trust disputes that this improvement action should be described as applying "across the whole service". Proposed revision: " Improve infection control measures in <specify non compliant service area>, to protect patients from infection through cross contamination.

Agreed

Amended to state: Improve infection control measures in the Emergency department and medical wards to protect patients from infection through cross contamination.

187

99

Outstanding practice and areas for improvement

Outstanding practice

Please include a reference to the points of innovation and outstanding practice that have been identified but not pulled through into this section.

 

These are the same as in the CIoH letter. The NQAG panel decided that the matters raised by the trust were not classed as outstanding practice in maternity.

188

101

Compliance Actions

Regulation 22

"….in A&E there were insufficient paediatric nurses to maintain 24 hour cover for children using the service".

“inflexible staffing arrangements were in place in the medical directorate to meet the needs of patients”

“in critical care, the level of staffing currently in place……to care for patients”

“the palliative care team could only support patients…. Due to staffing levels”

 

Propose remove: evidence supplied demonstrates that the specific points listed above are either incorrect or in line with the majority of trusts providing these services. For example, paediatric standard in A&E was and is met, staffing arrangements are not inflexible, critical care beds and staffing are not as described here, palliative care support at weekends is in most instances provided via oncall, as it is at HHCT.

Not agreed

As outlined in comment 4 and throughout the repot and FAC commentary.

 

101

Compliance actions

Regulation 20

"….throughout medicine, emergency and surgery areas".

 

Propose revision: please assign this action to the specific areas in which the deficits were found – this generalisation ignores the vast array of good records evidenced throughout the draft report.

Not agreed

The trust must have  inplace systems to ensure that all records are in line with their policies and national guidance.

188

102

Compliance Actions

Regulation 10

"….because they do not have an effective system in place to monitor and evaluate complaints".

Please revisit the wording of this action once the factual accuracy response is fully considered.

Agreed

Sentence amended to state: The provider must ensure that all complaints are identified and responded to in a timely manner.

189

102

Compliance Actions

Regulation 11

"The provider is failing to take steps to respond to any allegation of abuse…."

 

Please revisit the wording of this action once the factual accuracy response is fully considered.

Agreed

Sentence amended to state: The provider must ensure that they take proper steps to respond to any allegation of abuse.

190

103

Compliance Actions

Regulation 12

Please apply this to the specific areas that were non-compliant

Agreed

Sentence added: We found staff were not washing their hands in A&E Apple Tree ward, Cherry Tree ward, Walnut ward and in the Treatment Centre.

191

104

Enforcement actions

Actions we have told provider to take

Please confirm that there are no enforcement actions arising from this inspection

 

There are currently no enforcement actions arising from this inspection.

192

72 - 74

Neonatal Services

 

Please remove these pages as Neonatal services are not provided

 

The IT tool used to generate the report had to be re set and these were added in by mistake. They will be removed for the final version of the report.

193

75 - 77

Services for children and young people

 

Please remove these pages as Services for children and young people are not provided

 

The IT tool used to generate the report had to be re set and these were added in by mistake. They will be removed for the final version of the report.

194

78 - 80

Transitional Services

 

Please remove these pages as Transitional services are not provided

 

The IT tool used to generate the report had to be re set and these were added in by mistake. They will be removed for the final version of the report.

 

 

Completed by (name(s))

Frances Carey

Position(s)

Director of Governance & Risk

Date

26 November 2014

 

 

 

 

 

 

 

 

 

Account Number:

RQQ

Our reference:

SPL1-1378293871

Provider name:

Hinchingbrooke Healthcare NHS Trust

Provider address:

Hinchingbrooke Hospital

Hinchingbrooke Park

Huntingdon

Cambs

PE29 6NT

 

Ref #

Page

Report

Section

Suggested Changes with Explanation

CQC decision

CQC

1

1

Provider report

Ratings

"Overall rating for this trust.... Inadequate. Are services at this trust safe.... Inadequate. Are services at this trust caring.... Inadequate. Are services at this trust well led....Inadequate."  It is the trust’s strong submission that, once the factual inaccuracies have been remedied in the domains of the location report for Hinchingbrooke Health Care NHS Trust, and the wealth of quantitative and qualitative data available to the CQC is included in its considerations, the CQC will be left with residual evidence that contains both characteristics of ‘good’ and “requires improvement’ as set out in the Provider Handbook for NHS acute hospitals. The Trust submits that in the light of the factual accuracy submissions made, there are no reasonable grounds to maintain a rating of ‘inadequate’ for these domains at Hinchingbrooke Health Care NHS Trust. Inspectors of some of the service domains appear to have reached conclusions based predominantly on the limited observations and interviews during of the onsite inspection period without appropriate triangulation and due regard to more detailed relevant data and feedback available to the CQC for the relevant periods. The limited use of the information available to the CQC and the subjectivity demonstrated in certain sections of the report is not in keeping with CQC methodology and undermines its decision on ratings.

Not Agreed

CQC has taken into account all of the relevant evidence in relation to this matter, from all sources, in order to reach a determination on each of the factual accuracy challenges, as set out below in our detailed response. This has resulted in a number of changes to the location report as set out below. The ratings remain as before. See the detailed responses in the body of the location FAC comments. Therefore, applying the aggregation principles the ratings the trust is rated overall as inadequate

2

2

Provider report

Letter from the CIH

the trust management have adopted the 'Circle approach'.

 

Propose revision: 'The Trust's governance is derived from the Franchise Agreement and Intervention Order approved by the Secretary of State for Health (SoSfH).'

Agreed

Amended to state: The Trust's governance is derived from the Franchise Agreement and Intervention Order approved by the Secretary of State for Health.

3

2

Provider report

Letter from the CIH

predominantly run by hospital consultants from a neighbouring hospital... The trust was still medically led.' 

 

Propose revision: Remove 'predominantly run by hospital consultants from a neighbouring hospital' as this is not correct. Please amend text in this paragraph to read as 'It is led by a multidisciplinary team of clinical and non-clinical executives with operational accountability to Circle and public accountability through a Trust Board comprising a Chair and two Non-executive Directors.

Agreed in part

Sentence changed to state: It is led by a multidisciplinary team of clinical and non-clinical executives partnered with a non-executive Trust Board. However we found that the trust was predominantly medically led although a new director of nursing had been appointed four months prior to our visit.….”

4

2

Provider report

Letter from the CIH

The descriptor 'Trust Development Agency' should be 'Trust Development Authority'.

 

There is inconsistency in this within the report.

Agreed

Amended

5

2

Provider report

Letter from the CIH

Walnut Tree Ward' 

 

Propose revision: 'Walnut ward'

Agreed

Amended

6

2

Provider report

Letter from the CIH

"attended one board meeting'

 

Propose revision: "attended the Annual Public Meeting [i.e. the Annual General Meeting] on 25 September 2014"

Agreed

Amended

7

2

Provider report

Letter from the CIH

"There was a lack of paediatric cover within the A&E department, theatres and wards that meant that the care of children in these departments was, at times, unsafe."

 

Propose remove: The trust has not met aspirational targets in respect of paediatric cover but has met national standards. Evidence provided.

Agreed in part

We have checked with our specialists in this field and considered the evidence you have supplied. We have amended to state There was a lack of paediatric cover within the A&E department and theatres that meant that the arrangements for the care of children in these department was, at times, liable to give rise to risks to patient safety.  The RCN guidance, 2003 amended 2013 states that in DGH mixed emergency departments, a minimum of one registered children’s nurse with trauma experience and valid EPLS/APLS training must be available at all times. All other registered nurses caring for children must attain and maintain the minimum knowledge, skills and competence outlined above. As the hospital did not have one registered children’s nurse on at all times in the A&E department the service was liable to give risk to children’s safety. In respect of the operating theatre Surgery for children – delivering a first class service produced by The Royal College of Surgeons of England 2007 states that children in the operating theatre should be cared for by operating department staff that have specific paediatric skills and training. At the time of our inspection sufficient staff did not have these specific skills and training.

8

3

Provider report

Letter from the CIH

was so poor that patients were soiling themselves'.

 

The Trust challenges the accuracy of this statement. As written, it would lead the reader to believe that all patients were soiling themselves. Please define the number of patients for whom this was the case, out of a total number of patients interviewed and the total number of patients admitted to the wards in which this arose as a concern. Please confirm how this was evidenced.

In part

 

Amended to state “two patients of the 53 we spoke to in the medical and surgical areas stated that they had been told to soil themselves. A further one patient reported that they had soiled themselves whilst awaiting assistance. We brought this to the attention of the trust and they investigated. However neither CQC nor the trust could corroborate these claims.” This was evidenced through talking to patients. There was no documentary evidence recorded by nursing staff which either supported or negated these statements. 

9

3

Provider report

Letter from the CIH

"Risk assessments, although at times undertaken, were not reflective of the needs of patients."

 

Propose revision: "Risk assessments were not always reflective of the needs of patients."

Agreed

Amended to state: Risk assessments were not always reflective of the needs of patients in surgery and medical wards.

10

3

Provider report

Letter from the CIH

"Medicines were not always stored or administered appropriately."

 

Propose revision: "IV fluids were not always stored appropriately. Errors and omissions in medications adminstration were observed on <please state exact number/out of the total number of prescriptions reviewed" in some areas of the trust.

Amend

Amended to state: Medicines were not always stored or administered appropriately in A&E, Juniper ward, Apple Tree ward or Cherry Tree ward.

 

 

11

3

Provider report

Letter from the CIH

Ensure an adequate skill mix in the emergency department, theatres and wards, to ensure that patients of all ages receive a service that meets their needs in a timely manner.

 

Propose remove: The trust has not met aspirational targets in respect of paediatric cover but has met national standards. Evidence provided in respect of skill mix, patient experience and ED performance.

Not agreed

Amended to state: Ensure that the arrangements for the provision of services to children in A&E, operating theatres and outpatients areas provided by the trust, is reviewed to ensure that it meets their needs, and that staff have the appropriate support to raise issues on the service provision. Separate bullet added

Ensure that there are sufficient appropriately skilled nursing staff on medical and surgical wards to meet patients’ needs in a timely manner

12

3

Provider report

Letter from the CIH

Ensure pressure ulcer care is provided in accordance with NICE guideline CG179'

 

Propose revision: 'Ensure pressure ulcer care is consistently provided in accordance with NICE guideline CG179.

Agreed

Amended

13

3

Provider report

Letter from the CIH

Juniper Wad'

 

Propose revision: 'Juniper ward'

Agreed

Amended

14

3

Provider report

Letter from the CIH

"Risk assessments, although at times undertaken, were not reflective of the needs of patients in surgery and medical wards".

 

The Trust challenges the accuracy of this statement and seeks to understand in how many cases this was observed to be the case. As written, it would lead the reader to believe that all patients in surgery and medical wards did not have accurate risk assessments. Whilst the Trust accepts that CQC may have found some risk assessments that were not reflective of changing needs, the Trust disputes that this finding applied to all patients in all of these wards. Please define the number of risk assessments in which this was the case, out of a total number of risk assessments reviewed. Please confirm how this was evidenced.

Agreed in part

Sentence amended to state: This was evidenced by review of 46 sets of notes of which 19 were found to have incomplete information or review. This does not affect the comment as it is clear from our evidence that risk assessments were not always completed.

15

4

Location report

Letter from the CIH

Take action to ensure that when pre-alert telephone calls are received by the A&E department, action is taken to ensure a timely response.'

 

Propose remove: As evidence on page 20 of the location report evidences, concerns were not raised in respect of this: "We looked at a pre-alert form with regards to a pre-alert that occurred during our inspection, and found that the forms had been completed fully, with any clinical observations recorded, estimated time of arrival of the ambulance to the accident and emergency department, and details of who took the information over the telephone from the ambulance service."

Agreed

Removed

16

4

Provider report

Letter from the CIH

Ensure that all patients receive timely referral to the palliative care service.'

 

Propose revision: 'Ensure that all appropriate patients receive timely referral to the palliative care service.'

Agreed

Amended to state: Ensure that all appropriate patients receive timely referral to the palliative care service.

17

5

Provider report

Background to Hinchingbrooke Health Care NHS Trust

"attendance at a public board meeting on 25 September 2014"

 

Propose revision: "attended the Annual Public Meeting [i.e. the Annual General Meeting] on 25 September 2014"

Agreed

Amended to state: attended the Annual Public Meeting [i.e. the Annual General Meeting] on 25 September 2014

18

5

Provider report

How we carried out this inspection

"attendance at a public board meeting on 25 September 2014"

 

Propose revision: "attended the Annual Public Meeting [i.e. the Annual General Meeting] on 25 September 2014"

Agreed

Amended to state: attended the Annual Public Meeting [i.e. the Annual General Meeting] on 25 September 2014

19

5

Provider report

Background to Hinchingbrooke Health Care NHS Trust

Please cross reference with previous comment relating to Page 2. The Trust has not adopted the ‘Circle Approach’ for governance the governance is derived from the Franchise Agreement and Intervention Order approved by the SOSfH.

Agreed

Amended

20

5

Provider report

Background to Hinchingbrooke Health Care NHS Trust

Please change "Hichingbrooke" to "Hinchingbrooke"

Agreed

Amended

21

6

Provider report

How we carried out this inspection

"Thursday 25 to the public board meeting,"

 

Propose revision: "Thursday 25 September to the Annual Public Meeting [i.e. the Annual General Meeting] "

Agreed

Amended

22

6

Provider report

What people who use the trust's services say

We heard from patients who were not in receipt of a service at the time of inspection that the trust was slow to deal with complaints'

 

Propose removal: the CQC has not evidenced how many patients stated this, in what time frame they had received a service from the hospital or the dates/ timeframes for submission and response to their complaints; these complaints may relate to historical service provision and deficiencies in response.

Agreed

Removed as relates to previous 12 months.

 

23

6

Provider report

What people who use the trust's services say

The cancer patient’s survey showed that patients were not always given the information they required, and that their pain was not always controlled well.'

 

Propose remove: The Cancer Patient Survey relied on is not recent and therefore the evidence is outdated. The Trust's own more recent survey more shows an improved and current picture.

In part

Whilst we would agree that the survey is out of date we use the same survey across all trusts to ensure consistency. The trusts report has not been reviewed by CQC and therefore new evidence and cannot be used.

24

7

Provider report

Facts and data about this trust

GMC - Enhanced monitoring (01-Mar-09 to 21-Apr-14)

 

Propose remove: The CQC is aware that this has only remained an open issue because a new publication has not yet been uploaded that reflects that this issue was closed some months ago.

Not agreed

This was the situation at the time of the inspection and was reflected in the data packs. Having checked the GMC website we would agree that these issues are resolved but monitoring for sustained change continues.

25

7

Provider report

Facts and data about this trust

Serious incidents [STEIS] (April 2013 - May 2014) 102

 

Propose revision: As notified and agreed prior to the inspection, the  number of serious incidents experienced and reported to STEIS by HHCT in this time frame was 41.

Agreed

Amended

26

7

Provider report

Facts and data about this trust

HSMR: IM indicator No evidence of risk

 

Propose revision: Please include actual figure and context: 'HSMR April 13 - March 14  HSMR = 78.06; 'statistically lower than expected'

Not agreed

Data we hold contradicts this as Dr Foster Intelligence shows that the trust’s HSMR for 2013/14 was 92 (‘as expected’). As it’s not clear what the figure 78.06 signifies comment not amended.

27

7

Provider report

Facts and data about this trust

SHMI IM indicator No evidence of risk

 

Propose revision: Please include actual figure and context: 'April 13 - March 14  SHMI = 1.009; 'as expected'

Not agreed

As the figures will not mean anything to the general public so we do not include them.

28

7

Provider report

Facts and data about this trust

National reporting and learning system (NRLS) (April 2013- May 2014) Deaths 5, Severe 31, Moderate 86 Total 122.

 

Please replace with updated figures published in September 2014: NRLS [1 October 2013 to 31 March 2014] Deaths 2, Severe 19, Moderate 40 Total 61

Not agreed

The ‘total’ given is the number of notifications of moderate or severe harm or death (i.e. excludes no/low harm incidents).

The figures given by the trust come from an NRLS publication covering a different time period to IM.

29

7

Provider report

Facts and data about this trust

In section on Caring: CQC Inpatient Survey and Cancer patient experience survey.

 

Please provide details of the year of each survey used

Agreed

Amended

30

7

Provider report

Facts and data about this trust

Bed occupancy… 82.7%

 

Propose revision: "Bed occupancy… 95.2%"

Not agreed

We are unsure where the data presented by the trust is from as our information is from KH03 collection published by NHS England. The 82.7% figure is the published figure for overnight, consultant-led general and acute beds in Q4 (Jan – Mar) of 2013/14,

31

7

Provider report

Facts and data about this trust

Trust did not reach the 4 hour waiting time target two out of nine weeks.'

 

Why has the CQC selected a nine week period? This seems wholly designed to capture two breaches of target rather than to provide the reader with factual context.

 

As noted prior to inspection, the Trust's performance in July 2014 fell to 92.9%; its first monthly drop below a 95% achievement. Year to date figure was 95.2%. HHCT met all national performance indicators in 2013-14 with the exception of six week diagnostic standard.

 

Propose revision: "The Trust's four-hour waiting time performance in July 2014 fell to 92.9%; its first monthly drop below a 95% achievement. Year to date figure was 95.2%, which compares favourably with other NHS trusts."

Agreed

Out of 52 weeks which ended in 2013/14, the trust missed the 95% target 13 times. Hinchingbrooke was above the England average in 38 of 52 weeks, or 73% of the time. However the figures in the trust’s proposed revision are correct. Over the 17 weeks which ended in April – July 2014:

  • The England average was 95.1% compared to the trust’s 95.2%.
  • The trust missed the 95% target in 7 weeks. Its worst performance was in the week ending 20 July when more than 10% of patients waited over 4 hours for admission, transfer or discharge.

On balance we have amended the sentence to state Out of 52 weeks which ended in 2013/14, the trust missed the 95% target 13 times. Hinchingbrooke was above the England average in 38 of 52 weeks, or 73% of the time. However the current year to date figure is just over 95% which is in line with the expected average.

32

7

Provider report

Facts and data about this trust

"Cancelled operations No evidence of risk"

 

Propose revision: include the actual figure of 0.86% for the first two quarters of 2014/15 and a comparison with England performance

Not agreed

The IM reports include quarterly figures:

  • July’s IM included figures from Q4 2013/14 which showed the trust cancelled 0.8% of operations compared to an average of 0.9%.
  • December’s IM, just published, has figures from Q1 of 2014/15 showing that the trust cancelled 0.9% of operations compared to an expected 0.8%.

33

7

Provider report

Facts and data about this trust

GMC training survey: The trust rated worse than expected for 1 out of 12 sections, which was feedback

 

Propose revision: 'The Trust was within the middle quartile for 11/ 12 sections, including clinical and educational supervision and  workload, but was a below outlier on 1 section, which was feedback. Please provide details on which year of survey'

Agreed

The results are from the 2014 survey (carried out 26 March to 8 May 2014, results published June 2014 by GMC). The data pack incorrectly cites the 2013 survey as its source.

There are no factual accuracy issues. Analysts understand that the response means “interquartile range” (IQR) rather than “middle quartile”. Out of 12 sections the trust was in the IQR for 11, meaning it was not in the top/bottom 25% of trusts for those sections. For one section, Feedback, the trust was a “below outlier” meaning that it scored significantly worse than average.

Sentence amended to :

“GMC Training Survey 2014: Out of 12 survey areas the trust scored within the interquartile range (so about average) for 11, but was significantly worse than expected for one area, which was Feedback”

34

8

Provider report

Summary of findings

This section only mentions 6 of the 7 services inspected. 

 

Propose revision: "However, the maternity department, critical care service and outpatients and diagnostics functioned well, and patients received good care, which was in line with national guidance."

Agreed

Amended

35

8

Provider report

Summary of findings

People were at high risk of avoidable harm or abuse

 

Propose remove: The evidence does not support either one of these assertions. The Trust has a statistically lower than expected HSMR [78.06] and an as expected SHMI [1.009], a low level of serious incidents on a background of high reporting of near miss and no harm incidents [41 serious incidents, 96.8% no/low harm, 0.01% death, reference NRLS report September 2014], high patient satisfaction rates and low levels of complaints. If the CQC feels that the evidence obtained during its inspection requires such a statement, then please revise to 'People in some areas of the trust were felt to be at risk of avoidable harm and we observed  [provide exact number ] interactions from agency and substantive staff that were neither emotionally supportive nor demonstrative of compassionate care.'

 

Intelligent Monitoring placed the trust in the lowest-priority risk band, but that needs to be balanced against specific concerns that the inspection found. Hence sentence changed to 'People in some areas of the trust were at risk of avoidable harm. The evidence in the location reports for A&E, Surgery, medicine and end of life care highlight these risks.

36

9

Provider report

Summary of findings

Staff recognised they need to do more to increase breastfeeding rates but they lacked plans to do this'

 

Propose removal: Breastfeeding initiation is >82%; comments made by staff were indicative of their aspirations to perform even better, as is evidenced by them working actively to achieve Level 2 of Unicef's Baby Friendly Initiative, having achieved Level 1 certification. This statement has been framed in a way that could lead a reader to believe there is low uptake that would indicate poor support by the Trust. It is not a fair reflection of performance.

Agreed

Amended to state The trust was achieving over 82% of women breast feeding their babies staff wanted to increase this further but lacked plans to do this.

37

9

Provider report

Summary of findings

"The franchise manager, employed by Circle,

 

Propose revision: 'The Franchisee Representative, employed by Circle'

Agreed

Removed paragraph reworded as described by the trust below (42)

38

9

Provider report

Summary of findings

"The chief executive of the trust reports to the franchise manager"

 

Propose revision:  "The chief executive of the trust reports to the franchisee representative"

Agreed

Removed paragraph reworded as described by the trust below (42)

39

10

Provider report

Summary of findings

"The governance system operates through the Circle Operating system."

 

The governance system does not operate through the COS. The COS is a continuous improvement system which forms part of and interacts with the governance systems. The trust governance system is derived from the Franchise Agreement and Intervention Order approved by the Secretary of State for Health"

Agreed

Amended paragraph now states: The trust's governance is derived from the Franchise Agreement and Intervention Order approved by the Secretary of State for Health , which aims to drive continuous quality improvement (CQI). This system involves three meetings per month reviewing governance, performance and finance, attended by representatives from each clinical area the chief executive and members of the executive team. Reports are then collated and discussed with the Circle Partnership, the NHS Trust Development Authority and Clinical Commissioning Group.

40

10

Provider report

Summary of findings

"Three monthly meetings".

 

Propose revision: "Three meetings per month"

Agreed

Amended as above

41

10

Provider report

Summary of findings

Paragraph should end with "and CCG."

Agreed

Amended as above

42

10

Provider report

Summary of findings

The CQC description of accountability does not reflect the Franchise agreement.

 

Proposed revision: “The Trust Board has public accountability obligations as set out in the Intervention Order and the Franchise Agreement. The Trust Board is not mandated to hold the Executive to account as a traditional Trust Board would do. The CQC might not have appreciated the distinction between the role of the HHCT Board in getting sufficient assurance to enable approval of the Annual Accounts and Quality Accounts (with the CEO as Accountable Officer) and the Franchise requirement for Circle to hold the Executive to account for their performance. The Board holds Circle to account for meeting the conditions of the Franchise. Circle has delegated management responsibility that includes holding the Executive to account.”

Agreed

Amended to state: The Trust Board has public accountability obligations as set out in the Intervention Order and the Franchise Agreement. The Trust Board is not mandated to hold the Executive to account as a traditional Trust Board would do. The Board holds Circle to account for meeting the conditions of the Franchise. Circle has delegated management responsibility that includes holding the Executive to account

43

10

Provider report

Summary of findings

What is the CQC evidence relied upon to make the statement “information did not flow from the executive team to the staff at ward level”? Staff at ward level sit on the Board meetings and there are other methods of dissemination.  This is potentially an unfair judgement based on insufficient evidence.

Agreed

We spoke to front line staff at all grades from across the cores services who told us that they did not receive information on decisions made at the governance meetings. Whilst senior clinical staff sit at these meetings information was not consistently passed to ward staff. Staff meeting minutes which we were able to access did not highlight that information was passed to ward staff.   We have amended the sentence to state: Despite mechanisms put in place by the trust staff, we spoke to, reported that they did not always receive feedback from the executive team meetings.

44

10

Provider report

Summary of findings

However, we did not find that the challenge was robust, nor were trends analysed, or conclusions and actions drawn from these. 

 

This Trust requests that additional text is added to provide context to this statement.

 

Propose revision: 'However, we did not find that the challenge was robust, nor were trends analysed, or conclusions and actions drawn from these. Performance and quality issues were also discussed in the Performance and Commissioning Board, which we did not attend, and are supported by a detailed pack including trends and clear records of the actions that have been taken.  Local Performance is discussed within the divisions at monthly Divisional Performance meetings. These meetings discuss trends and performance issues along with the actions agreed to address them. The CQC were not present at any of these meetings but received evidence of this during the inspection. The CQC was informed that plans were in place to amalgamate these two meeting groups in October, to improve the clarity of governance. The first amalgamated meeting was held in October 2014, as planned.'

Agreed in part

Whilst we did not attend other meetings we reviewed minutes of these meetings and spoke to senior staff about them. We were informed of plans to amalgamate these meetings but this was not in place at the time of the inspection. Sentence amended as per proposal apart from the last sentence which states 'However, we did not find that the challenge was robust, nor were trends analysed, or conclusions and actions drawn from these.

Performance and quality issues were also discussed in the Performance and Commissioning Board, which we did not attend, and are supported by a data pack. Local Performance is discussed within the divisions at monthly Divisional Performance meetings. The CQC were not present at any of these meetings but received evidence of this during the inspection. The CQC was informed that plans were in place to amalgamate these two meeting groups in October, to improve the clarity of governance. The trust told us that the first amalgamated meeting was held in October 2014, as planned.

45

10

Provider report

Summary of findings

"The executive board, trust board and the Circle Partnership were unaware of significant issues threatening the delivery of safe and effective care on this ward until it was evident in the media".

 

Propose remove; this is factually incorrect. The Trust Board was made aware of the issues on Juniper Ward both orally and in writing on Friday 8 August following an internal major incident being called on Wednesday 6 August 2014

In part

On reviewing the interview notes made at the inspection we found that this is what we were told at interview with the trust board. However reviewing the notes that were sent the document entitled Time Line and log of events– Stop the Line Juniper dated 18 August 2014 states that a major incident was called around 13.00 on 7 August 2014. Therefore this statement amended to The trust board and the Circle Partnership were unaware of significant issues threatening the delivery of safe and effective care on this ward until a major incident was instigated.

46

10

Provider report

Summary of findings

The Executive Board, Trust Board and Circle Partnership were unaware of significant issues threatening the delivery of safe and effective care on this ward (Juniper) until it was evident in the media.

 

Propose remove: This is factually inaccurate. Concerns in respect of Juniper Ward were raised previously and discussed within Divisional monthly meetings. Initial concerns and performance anomalies were present in the May Divisional Performance pack, along with actions taken as a result. The division had flagged staffing levels as a risk in the local risk log and the corporate risk register; a divisional head of nursing assumed the duties of ward matron to support the team. The Executive team were fully aware of the issues on Juniper Ward and actions that had been put in place. Email evidence of this, together with action plans, divisional performance packs are submitted as evidence of awareness and actions taken. E52

In part

Having reviewed the divisional and ward dashboards submitted whilst a number of indicators were showing red ratings little or no improvement was noted in June 2014. Neither dashboard demonstrates the actions taken. The risk register for GI shows one risk for medical staff on Juniper dated 1 September 2014. However email trail demonstrates that both parties were informed of a major incident being declared. Sentence amended as above.

47

10

Provider report

Summary of findings

"Some staff told us they had been actively discouraged by managers from calling a stop the line meeting" 

 

Based on this draft report alone, the Trust is unable to check the factual accuracy of this statement. Therefore the Trust requests that the CQC provides the exact number of staff who alleged this from the number of staff interviewed and request confirmation that CQC triangulated this information to be certain that this did not relate to incidences where a 'Stop the Line' activity would have been inappropriate or unnecessary, e.g. if an issue was already being actively managed.

Not Agreed

We asked almost all staff about the stop the line process. 10 staff told us that they had been actively discouraged from calling a stop the line. We asked to see the data for the stop the line process and found that these were rare events. We triangulated the information staff gave us with the stop the line process outlined. None of the two incidents were listed.

48

10

Provider report

Summary of findings

We found that there were significant care issues on one ward, Apple, which we identified immediately upon inspection and which were not identified through review of performance dashboards, nor were they raised at this meeting.

 

Propose revision: We found that there were significant care issues on one ward, Apple, which we identified immediately upon inspection and which were not identified through review of performance dashboards, nor were they raised at this meeting; however, the ward has a reporting rate of 98.4% no/low harm incidents, which is indicative of a positive reporting culture.' An internal quality review of the ward, undertaken by the Trust on 15 July 2014, highlighted some issues for improvement but nothing of the scale allegedly identified by CQC, indicating that this had  been a recent emergent risk.

In part

Whilst the rate of reporting may indicate a reporting culture it is irrelevant here as no one reported this as an occurrence. There was also a lack of willingness by anyone in the trust to call a stop the line in this instance.

49

11

Provider report

Summary of findings

"some staff told us that whilst they had been consulted about the running of the Trust, the Trust management team had failed to act on or explain why changes suggested had not materialised."

 

The Trust requests clarification on this statement and requests details of the changes referred to by the CQC.

Clarification

At five focus groups staff told us that they had suggested ways of improving the service to patients. These had not been acted upon by the trust nor had the reasons why been explained to staff.  We cannot give instances of what changes had been suggested to management as this would identify the staff groups concerned. However it was across grades of staff.

50

11

Provider report

Summary of findings

"We found that this was a medically-led organisation, and we were concerned at the difficulty in ensuring that the important voice of the nursing staff was heard and enacted, thus impinging on the quality and safety of care for patients."

 

The trust requests that this paragraph is removed or amended to provide an accurate description of the organisation.  Like a large number of other NHS Trusts, the Trust has a medical director and clinical directors leads for each clinical division, all of whom are members of HHCT's executive team.  This structure is replicated in most NHS hospitals in England.  Other professionals are involved through the management structure, including a Director of Nursing, Midwifery and Quality, a nursing qualified Chief Operating Officer (both of who are members of the Executive Board), supported by an Associate Director of Nursing and divisional head nurses supporting clinical divisions. The Trust request clarity from CQC regarding the evidence relied upon by CQC that gave rise to the statements in the report. 

Not agreed

The trust wide team discussed this at length with the CEO. Whilst we recognise that there are three people on the executive team with a nursing background there was little support for the director of nursing in promotion of the nursing voice. This was triangulated through minutes of meetings and through speaking to senior nursing staff who felt that their views on proposed changes were not heard.

51

11

Provider report

Summary of findings

"the trust met with all employees to devise their credo."

 

The Trust did not meet with all employees to devise the Credo. The Credo is from Circle’s foundation. The Trust actually met with large numbers of employees to set the annual business plan (the 16 point plan based on the Quality Quartet and the Trust's known AFI. The Trust requests that this statement is amended to reflect the true context.

Agreed

Amended to state The trust met with a large number of employees to set the annual business plan.

52

11

Provider report

Summary of findings

"Reviewed the incident reporting mechanisms and adoption of the Datix system."

 

The Datix System has not been adopted as a result of the CQC findings but was pan extension of the system used in other Circle organisation and had been planned from March 2014.  Other system investments, such as Allocate Health Assure for CQC Assure, NICE Assure, Audit Assure and Board Assurance Framework (BAF) were purchased ahead of the inspection. Implementation was deliberately phased until after the CQC inspection so as not to overload staff with new system roll outs and a CQC inspection at the same time.

 

The Trust requests that this statement is amended to reflect the true context.

Agreed

Amended to state Reviewed the incident reporting mechanisms and expansion of the Datix system.

53

11

Provider report

Summary of findings

On what evidence do the CQC base the judgement that they were concerned in the difficulty in ensuring “the important voice of nursing staff was heard and enacted etc…” when nursing staff sit on the Board.

 

Where has this evidence been triangulated?

 

As outlined above

54

12

Provider report

Summary of findings

"monthly meetings in the areas of performance, finance and integrated governance".

 

As before, the Trust holds three separate monthly meetings.  The Trust requests that the statement is amended to reflect this fact.

Not agreed

We agree that the trust holds three monthly meetings but this is what this sentence means.

55

12

Provider report

Summary of findings

"This meant that there were gaps in the reporting into the governance structures and the trust may not be aware of the issues of concern."

 

In the absence of any detail, the Trust is unable to challenge this statement.  The trust requests CQC to provide evidence of the gaps they have identified and if these cannot be provided the Trust requests that this statement is removed or amended to reflect the true context.

Not agreed

Gaps included robust data analysis to provide reasonable assurance.  The trust have merged the performance and integrated governance meetings and reviewed its dashboards since our inspection and in light of issues raised on Juniper and Apple Tree ward which were not reflected in the current dashboards.

56

12

Provider report

Summary of findings

Typographical error: Please amend "form" to read as "from".

Agreed

Amended

57

12

Provider report

Summary of findings

" no robust challenge or trending at the meeting".

 

The Trust is concerned that CQC has continuously relied upon their partial attendance at one Integrated Governance meeting to demonstrate a lack of challenge, yet had not attended any of the other executive meetings.  The Trust is particularly concerned that the CQC attendees only observed one hour and 20 mins of a three hour meeting.  They were not present to witness the entire proceedings of the full meeting and therefore missed a substantial amount of debate and discussion. Issues, and trend analysis, were present in the quality reports presented at this meeting after inspector departures and are Minuted. Equally, the issue of falls is discussed in the monthly performance meetings on key performance indicators.  Despite the Trust explaining in detail the structure of its committees and their roles and responsibilities, CQC has not accurately reflected this in the report. Evidence has been provided throughout the location report sections to support this.

Not agreed

We reviewed all minutes of meeting sent by the trust in relation to IGC and performance meetings. None showed a robust challenge or trend analysis of data. This would allow the trust to identify issues such as those that occurred in relation to Juniper ward.  CQC have replicated what they were told by senior staff including the CEO of the governance structures and sought to clarify this with the trust to ensure that it was factually accurate. Sentence amended to state: no robust challenge or trend analysis at the meeting

58

12

Provider report

Summary of findings

"A further directorate reported that they had also seen a rise in falls, but there was no discussion about what the Trust as a whole could do, to support these two directorates in managing a reduction in falls, or to raise awareness across the Trust".

 

This statement is not an accurate reflection of the true context and the Trust requests that additional text is provided to address this lack of context. Propose revision:

 

A further directorate reported that they had also seen a rise in falls, but there was no discussion in this meeting about what the Trust as a whole could do, to support these two directorates in managing a reduction in falls, or to raise awareness across the Trust. This issue had, however,  been addressed in the earlier Performance and Commissioning Board meeting held in September (August data), which inspectors did not attend. Minutes from this meeting show the actions agreed Trust wide to address the increase in falls, including a falls action plan to be shared Trust wide and a further investigation commenced into falls. The context of hospital wide issues of concern was in the Top Ten Report later presented after the withdrawal of the inspectors from the Integrated Governance meeting. The Clinical Commissioning Group (CCG) had previously congratulated HHCT in its performance on reducing harm from falls and had asked permission to share its approach with other Trusts.'

Agreed in part

We cannot comment on your report that it was discussed at the Performance and Commissioning Board as we have not received this.

 

We were told by the CEO and senior members of the trust that the IGC was the forum where confirm and challenge occurs.  There was no evidence of this. Further, not all members of the Integrated Governance Committee attend this meeting on a regular basis as outlined by the rolling attendance figures provided by the trust.

 

Sentence amended to state: We attended part of the integrated governance meeting as we were told by the chief executive and other senior staff that this is where confirm and challenge takes place. We attended this meeting for approximately 1.5 hours and found that there was no robust challenge from other members of the meeting or trend analysis occurring at the meeting we attended. For example, the medical directorate stated that they had seen an increase in falls, and that they were taking steps to address this. A further directorate reported that they had also seen a rise in falls, but there was no discussion about what the trust as a whole could do, to support these two directorates in managing a reduction in falls, or to raise awareness across the trust. The trust stated that this discussion had been held at the Performance and Commissioning Board meeting however we were unable to confirm this.

59

12

Provider report

Summary of findings

They stated that the trust's executive team was held to account by the Circle Partnership team through the Franchise Manager," Propose revision: 'They stated that the trust's executive team was held to account by the Circle Partnership team through the Franchisee Representative.'

Agreed

Amended to state Franchise Representative

60

13

Provider report

Summary of findings

Even during the discussion of this issue with the CEO, it was the CQC who called a 'Stop the Line', not the trust.

 

Propose remove: The CQC alerted the CEO of concerns, following which he called a 'Stop the Line'. Point of clarification: the stop the line was not 'called' by CQC

Not agreed

The CEO stated “So you are calling a Stop the Line” to the Head of Hospital Inspection and the Inspection Chair.

61

13

Provider report

Summary of findings

In relation to an article in the press alerting to issues on Juniper Ward via the Media the CQC state “both”.  Does this mean two people interviewed on the Trust Board or does it mean The Trust Board and the Circle Exec? In any event it is not a correct statement. Check and challenge.

Agreed in part

One person at the trust board told us this. However subsequent to further information provided the sentence has been amended to state: The trust board and the Circle Partnership were unaware of significant issues threatening the delivery of safe and effective care on this ward until a major incident was instigated

62

13

Provider report

Summary of findings

The CQC state, “They found the STL meeting to be focussed on the identification of the people involved….and blame”. 

 

Please remove: This is held by the Trust to be a distortion of content; the Trust clearly could not assess risk or manage improvement without knowing exactly who was involved in the alleged incident and the context of their involvement. This is a matter of opinion of the two CQC staff present at the SWARM and also the same two CQC staff who made allegations about staff on Apple Tree Ward.

Not Agreed

We have considered your point that improvement and action could not be taken without knowing the identity of the alleged perpetrators. However this statement clearly states that this is the opinion of the people in attendance at the SWARM. These were the same two people who had seen the behaviours of the staff employed by the trust on Apple Tree ward and who were requested to attend the SWARM by the trust.

63

13

Provider report

Summary of findings

CQC claim the minutes of IGC do not demonstrate evidence of challenge of reds on dashboards. The trust asserts that this may be more a reflection of Minutes accuracy than evidence of lack of challenge.

Agreed

Accurate recording is important to ensure a true reflection of the meeting. Through accurate recording those matters that are the subject of challenge are flagged and recorded so that they can be addressed. If these are not present the trust cannot demonstrate the challenge and any subsequent action taken.

64

13

Provider report

Summary of findings

"both responded that it had been the article in the press which had alerted them to the issues".

 

Propose remove: This is factually incorrect. The Trust Board was made aware of the issues on Juniper Ward both orally and in writing on Friday 8 August following an internal major incident being called on Wednesday 6 August 2014. Evidence of email trails, action planning and response have all been provided within the appropriate section of the location report.

Agreed

As per comment 61. On reviewing the notes that were sent the document entitled Time Line and log of events– Stop the Line Juniper dated 18 August 2014 states that a major incident was called around 13.00 on 7 August 2014. Having reviewed the interview notes made at the inspection we found that this is what we were told at interview with the trust board. Therefore this statement amended to “The trust board and the Circle Partnership were unaware of significant issues threatening the delivery of safe and effective care on this ward until a major incident was instigated.

65

14

Provider report

Summary of findings

"This triumvirate reported in through the integrated governance meeting to the board.

 

Propose revision: "This triumvirate reported in through the integrated governance meeting to the Executive Board".

Agreed

Amended to state: This triumvirate reported in through the separate committee meetings to the executive board in addition to the monthly divisional performance meetings to review performance and quality issues.

66

14

Provider report

Summary of findings

"This reliance on dedication rather than recognising the necessary support and time required, significantly impaired the ability to run a hospital with the complex problems that an acute NHS trust will experience."

 

Propose remove: The Trust disputes this statement and requests that CQC provides clarification of how it reached the judgement of "significantly impaired" and the evidence it relied upon. .

Clarification

The CEO recognised in his interview that the time allotted to clinical leads was insufficient and stated that Circle shares would be coming into force which would recompense staff for the extra time they gave to administer these duties. He recognised without this good will they could not fulfil these job roles. This would therefore potentially impact upon the ability to undertake the effective running of the hospital. Sentence amended to state: This reliance on dedication, rather than recognising the necessary support and time required, potentially impaired the ability to run a hospital with the complex problems that an acute NHS trust will experience.

67

14

Provider report

Summary of findings

"Some leaders were new and inexperienced." The Trust requests clarification of the evidence CQC used to reach this judgement, in particular how many leaders are classified as "inexperienced" and on what basis? In all NHS trusts, it is normal practice for leaders to be of varying levels and experience. This enables Trusts to support staff in their development and supports the opportunity for succession planning. 

Agreed in part

The inspection team spoke to 15 leaders within the inspection of which 5 stated that they did not feel supported to undertake their new role. Sentence amended to state: and did not feel that they had the level of support to undertake their new roles.

68

14

Provider report

Summary of findings

"The trust board was involved in governance meetings within the trust and provided some critical challenge at these meetings."

 

This statement contradicts the earlier CQC judgement that there was no challenge at governance meetings.

 

The Trust requests that the previous comments are revised and amended to reflect this.

Agreed in part

The only challenge seen at the IGC meeting was from the non-executive trust board member. However this was limited and not robust as described earlier in the report.

69

14

Provider report

Summary of findings

""the nursing voice was less well established".

 

As described in earlier Trust comments regarding page 11, the nursing voice has representation in the clinical management structure and this has been strengthened by the recent appointment of an experienced Chief Nurse the Trust requests that CQC revise and amend this statement to reflect this.

Agreed in part

Having reviewed the bullet point to ensure clarity for the reader sentence amended to state: We found that the senior medical staff were involved in the management and review of the hospital, but that the nursing voice was less well established. The chief nurse was relatively new in post and was not well supported through nursing structures at the time of the inspection. Since the inspection an interim deputy director of nursing has been appointed. This is not a reflection on the abilities of the Chief Nurse but a reflection of the fact that she was new in post and was not adequately supported to champion the nursing voice.

70

14

Provider report

Summary of findings

CQC state that executive board members confirmed that internal systems had not highlighted significant concerns on Juniper Ward. Patient STL identified this and the EB and TB acted via EPRR response. Performance Board is part of the Integrated Governance System and issues on Apple Tree Ward and other Wards had identified concerns of which the Exec Board were aware and managing in relation to DTOC and IPC etc…..HHCT to check the data and ?challenge the judgement.

 

Requested removal from FAC process by Frances Carey 2 December 2014.

71

14

Provider report

Summary of findings

This triumvirate reported in through the integrated governance meeting to the Board.

 

Propose revision: ' The Hospital's organisational tree demonstrates that at the time of inspection there were four separate Executive Boards; the Membership of each is the same, comprising the full executive team, and the titular division merely reflects the planned scheduling of separate focus areas. In practice, the Executive Team has not complied strictly with this division of focus and, instead,has flexed each agenda to discuss key issues throughout the month. Inspectors attended part of only one of these meetings and so did not experience a comprehensive oversight of the discussions.   IN addition, directorate performance and organisational risk is discussed at monthly Divisional performance meetings held with Members of the Executive team. Packs are produced for these meetings that include data analyses, reviews of performance, quality issues and actions agreed from these meetings. The Performance and Commissioning Board is where the majority of discussions take place regarding performance, hotspots, trends and actions. The Trust has subsequently amalgamated its governance and performance committees.'

Agreed in part

CQC has explained the organisational structure in this bullet point in line with the trusts comments and amended this sentence in line with comment 65. Bullet reads: There was a new leadership structure in place. Each division was led by a clinical lead, a head of nursing and a manager. This triumvirate reported in through the separate committee meetings to the executive board in addition to the monthly divisional performance meetings to review performance and quality issues.

However the inspection team were regularly told that it was at the IGC meeting that confirm and challenge took place by senior members of the trusts team including the CEO.

72

15

Provider report

Summary of findings

The CQC judgement that the SWARM concentrated on identification of the people involved and once it had confirmed that its own staff were not involved failed to recognise that its staff had not appropriately supervised them raised concerns that there was a blame culture. This judgement is based on poor evidence and opinion of TWO CQC staff and evidence could be questioned.

Not agreed

As outlined above in comment 62.

73

15

Provider report

Summary of findings

What evidence do the CQC base the judgement that there was a disconnect between patient facing staff and the senior team in relation to planning and addressing of issues raised? The senior team (Exec Board) largely consists of patient facing staff. This appears to be based on miniature raised by one member of staff, how did CQC triangulate?

Clarification for trust

Senior clinical staff attend IGC but the executive board are managers of areas, such as divisional heads of services, and clinical leads, and are not day to day patient facing staff. This issue was raised by a number of staff through focus groups where they reported that they had raised issues to improve systems but these had not been discussed or outcomes of discussions not fed back to the staff proposing them. This was not a singular member of staff but many staff within focus groups. We cannot identify these staff as this would compromise the confidentiality   of staff participating in these focus groups.

74

15

Provider report

Summary of findings

"We looked at equipment which was visibly clean, but found that some equipment

Propose revision: "We looked at equipment which was visibly clean. The Trust achieves a 94% compliance rate in respect of servicing of equipment. The Trust has in the past experienced some issues when service labels were attached to the lead, rather than to the main body of the equipment, but this practice has been amended."

 

Added by Frances Carey 2 December 2014 However this line is not within the provider document. It is however in the location report and has been amended.

75

15

Provider report

Summary of findings

"Patients were routinely triaged within the waiting room area with no consideration for their privacy or dignity."

 

Propose revision: "Patients were routinely triaged within the waiting room area with no consideration for their privacy or dignity. This practice was not in line with departmental expectations; the Trust does provide a private room suitable for triage and expects staff to offer patients a choice."

 

Added by Francis Carey 2 December 2014 However this line is not within the provider document. It is however in the location report and has been amended.

76

16

Provider report

Summary of findings

"an example of this is the "Stop the Line initiative".  Again the Trust questions the breadth and depth of evidence used to support this judgement as it appears to rely again on the same single example of "Stop the Line".  The Trust requests that CQC provides further evidence beyond this example and questions the proportionality of this statement. The Trust request that this entire bullet point is removed unless further corroborated evidence can be provided.

Not agreed

We spoke to 245 member’s staff from across the trust about the stop the line process and many of these staff stated that they would not use this process as they had little faith in the process 10 staff told us that they had been actively discouraged from using it. A significant number of staff spoken to were also reluctant to use this process.

77

16

Provider report

Summary of findings

Typographical data:

 

Please remove as there is no comment associated with thisBP is absent of data

Agreed

Amended

78

16

Provider report

Summary of findings

"A series of meetings are held across the trust in order that staff can input their views into the credo."

 

This statement is inaccurate. The staff do not input their views into the Credo, they put them into the "16 point plan" and into CI through the COS. Propose revision: Please replace "credo" with "16 point plan.

Agreed

Amended to state: A series of meetings are held across the trust in order that staff can input their views into the 16 point plan.

79

16

Provider report

Summary of findings

"Once the serious issues we identified had been highlighted to the Trust, the management team delegated the senior nurses to speak with patients and their families affected."

 

The Trust is concerned about this statement as it infers that the senior management has delegated responsibility in a negative way.  It was agreed internally that these staff were the best placed to interact with the patients and their families. They were supported to do this. The Trust requests that this CQC statement is amended to reflect this context.

Agreed

Amended to Once the serious issues we identified had been highlighted to the Trust, the management team delegated the senior nurses to speak with patients and their families affected as the trust determined that these staff were best placed to do this.

80

16

Provider report

Summary of findings

"it is unclear what feedback the volunteers provided to the Trust"?

 

The Trust requests CQC to confirm what evidence is relied upon to reach this judgment and requests that CQC amend this sentence, given that in bullet point 3, CQC acknowledges that the Trust actively seeks the views of patients via the volunteers.

Not agreed

CQC acknowledges that the trust used the volunteers to gain feedback from patients but volunteers were not aware of a system for the volunteers to feedback information on their own views to the trust.

81

16

Provider report

Summary of findings

On what evidence have the CQC judged that the above demonstrated that there was limited ability to improve or engender innovation at the Trust?

Clarification

These two points (80 & 81) are not related. The bullet states that we could not be assured that either the trust board or Circle provided the confirm and challenge required to generate improvement and innovation. An example of this is the trusts actions taken in respect of Juniper ward when there had been no challenge raised in respect of the performance dashboards and no examples of lessons learnt and implemented across the trust.

82

16

Provider report

Summary of findings

“Very few staff were aware of the ‘Take a Break’ initiative” Based on the high profile communications and feedback from staff related to this the CQC should be asked to evidence the source and proportionality of the evidence and judgement.

Clarification

We spoke to 20 staff on a variety of areas including medicine and surgery that were unaware of this initiative.

83

17

Provider report

Summary of findings

"This demonstrated that there was limited ability to improve or engender innovation at the trust." 

 

The Trust questions the validity of this judgement and requests CQC to explain the evidence base for this judgement and to clarify the causal link between the perceived lack of "confirm and challenge" (which the Trust disputes) and the level of improvement and innovation. The Trust requests that this statement is removed.

Clarification

CQC interviewed both the trust board and representatives from Circle Partnership, we attended part of an IGC meeting and reviewed the minutes of all performance and governance meetings sent by the trust. There was a lack of confirm and challenge described in minutes and through the two interviews we saw the confusion as to whom provided appropriate challenge to drive innovation within the trust.

84

17

Provider report

Summary of findings

The CQC state that they, “saw little time set aside for teams to discuss performance indicators and to confirm and challenge each other on their performance targets.”

 

On what evidence is this based? This is potentially an unfair judgement.

Clarification

On speaking to members of staff across the trust and in reviewing local team minutes in A&E and medicine in particular we were unable to see time set aside to discuss performance indicators. A lack of evidence in this area formed the basis of this judgement. We have amended the statement to refer to these areas.

85

17

Provider report

Summary of findings

We saw little time set aside for teams to review performance indicators, and to ‘confirm and challenge’ each other on their performance targets. 

 

Propose remove: Performance indicators and targets are discussed within each Directorate, covering Risk and Governance, HR and Finance. Issues are then brought to the monthly divisional meetings led by the Executive team. Risks from the divisional meetings are then brought to the Performance and Commissioning board every month to be discussed at executive level.

Not agreed

There was little evidence that performance indicators were discussed at ward or departmental level as highlighted in A&E and medicine service reports. Amended to state: We saw little time set aside for teams to review performance indicators, and to 'confirm and challenge' each other on their performance targets. This was particularly evident in the medical and A&E department. There was a lack of ability to identify where issues may arise within the trust before a serious matter occurred.

86

17

Provider report

Summary of findings

What evidence do the CQC have to state, “CIP plans were not locally owned by staff”? CIP plans form part of the 16 point plan that staff participated in the creation of.

Agreed

Sentence removed.

87

18

Provider report

Table of ratings

Please cross reference with factual accuracy responses /

 

Done

88

19

Provider report

Bullet point 6 of Actions the Trust must take to improve

"... to ensure that patients of all ages…" The findings that gave rise to this judgement related to children and not "all ages".

 

The Trust requests that this is amended.

Not agreed

Bullet amended as per CIoH letter:

  • Ensure an adequate skill mix in the emergency department and theatres to ensure that paediatric patients receive a service that meets their needs in a timely manner.
  • Ensure that there are sufficient appropriately skilled nursing staff on medical and surgical wards to meet patients’ needs in a timely manner.

89

19

Provider report

Areas for improvement

"Disseminate the lessons learnt from incidents to ensure that quality of care for patients is improved."

 

Propose revision: " Standardise and improve the dissemination of lessons learnt from incidents to support the improvement of the provision of high quality care for all patients."

Agreed

Amended

90

21

Provider report

Compliance Actions

NO table has been included.

 

The Trust requests that they are provided with a copy of this draft table in advance of publication of the final report and that an opportunity is provided to complete a factual accuracy check on this within an appropriate timescale.

 

Amended following NQAG discussions  Compliance action added in respect of Regulation 10

91

21

Provider report

Enforcement Actions

NO table has been included.

 

The Trust requests that CQC confirms that there are no enforcement actions to be declared in this report.

 

There are no enforcement actions taken in this inspection and the table will be deleted.

 

Completed by (name(s))

Frances Carey

Position(s)

Director of Governance & Risk

Date

26 November 2014